|
STATE OF NEBRASKA
<br />IId&rrrtr,�fpide 9.x� x'kt991V11bfA(St�i gr06PfAPae o .-_ � a�66G9YNP1ft0C._
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />.BEA TRUE COPY OF 'TME ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, "VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAZE OF ISSGIA +ICE
<br />1/24/21122
<br />• LINCOLN, NEBRASKA
<br />Amended
<br />AEOEDENTS-NAMItia ;FJrat,
<br />Frank .,1 :Marik
<br />202400853
<br />Q1ei
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Middle, Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Howells, Nebraska
<br />7 ;S9CtA£: SECURITY N,UMSER
<br />5'06-+2^1249
<br />811 <'FACILtTY NAME {(t riot Insthudon, give street and number)
<br />Grand Island Lakeview Care & Rehabilitation Center
<br />Cc: CITY'OR TOWfi OPDFATH (include Zip Code)
<br />la t 1'lei red ; 801
<br />IM.IRESIDENCE-STATE
<br />Nebraska
<br />9d. STREET ASID NUMBER
<br />11812 Wi dsor f2Oad
<br />9b. COUNTY
<br />Hall
<br />541. AGE - Last<Btrthday
<br />(Yrs.)
<br />85:
<br />Bb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS. I DAYS
<br />Ba. PLACEOP DEATH
<br />',HOSPITAL, O inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />TAI STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME . (CNA MI
<br />Prank J `Malik
<br />0, Lest, Suffix)
<br />'.00,0 i1.14 US 1/4ii ARMED Give dates of service N Yes.
<br />(Yes, No, or Unk.) Yes .05/16/1955-05/05/1957
<br />18.�METHOD OF DII POSIT ON
<br />0 auitai y 0 Gelation
<br />3 cr It ort
<br />1:101.0.iiSmost
<br />j Relrlova Otilr (Specify)
<br />9c. CITY OR TOWN
<br />.Gran.d.Island
<br />HOURS
<br />MINS.
<br />21 18052
<br />3. DATE OP DEATH (Mo,
<br />December 5 +2021
<br />S. DATE OF rt.:.(Me., Day, Yr.)
<br />June26,
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home.
<br />0 Other (specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue
<br />Kathryn Ritzdorf
<br />112. MOTHER'S -NAME (First,
<br />Lillian Podliska
<br />14a. INFORMANT -NAME
<br />Kathryn Marik
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />ty..
<br />(MITE.
<br />Middle, Maidlnt Surname
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17e.. FUNEPIAL:.HOME;.NA,ME AND MAILING ADDRESS (Street, City or Town„State)
<br />:Area Funeral dome, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1A: Patti, Enter Machete of Monte- 4dssaeea, Nudes, or compiicationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular BsnUation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tithe If necessary.
<br />IMMEDIATE CAUSE:
<br />A39lc ueaglnsl a) gastrointestinal hemmorrhage
<br />in d+irnttl.. DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause gated
<br />an events TO
<br />LAST
<br />In
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />I DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />fdb RELA7IQII I TbDssete
<br />Wife'.
<br />184. OA 410-* Caye gni,
<br />December $ 2t 1'
<br />S
<br />N'ti asks
<br />18 PART I1 t)THER SIGNIFICANT CONDITIONS -Conditions contributing to the death but n zt resulting in the#inderlying cause given in PART 1.
<br />irCri de8(det10y, arterilit 2nd degree blood loss, Coronary Artery Disease, CHF, CKO stage 3'
<br />.20. IF FEMALE „
<br />•Natrl,agt):!#11llnpUt r
<br />ftregnent #Items of iiselh:
<br />O: NM per, but pr4gtf Ides waptn 42 days Of death
<br />0 Not pregnant. but pregdaa 4d days tet yew' before death
<br />p:unIInewntr.pd.9nanewahit#the Patti iear
<br />22e. OATEOF. J,tUW(510., My, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES_.QNQ :.
<br />224LOCATION'OF
<br />210. MANNER OF DEATH
<br />® Natural 0 Holllaide!
<br />Accident 0 Ponding Investigation
<br />0 SuicideCould not be determined
<br />22b. TIME OF INJURY
<br />21b iF TRANSPORTATION INJURY
<br />DrhteNOperator
<br />,:0 passenger
<br />oPedestrian
<br />0 Other (Specify)
<br />A$ i8EI1IC4 Exflll�INS
<br />CORONEROONTACTED?
<br />21d. WER16 AttroPsiiztfaiNGSAVAA
<br />TO COMPL ETEOl USE Of CUM?
<br />D YES ` CI-
<br />22d.
<br />I
<br />22c. PLACEOF 1NJURY Atitorne farm, street, factory, office building, construction el
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER APT.NO.
<br />23*. DATE `OP.DEATH (Mo., Day, Yr.)
<br />December 25, 2021
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />f Gertlber 27.2021
<br />23c. TIME OF DEATH
<br />04:03 PM
<br />*Wks best ophy.1010whidge, death occurred at the time, date and place
<br />eniidue to ins cause(a) st/Md, (Signature and Tree)
<br />Chad Vieth, MD
<br />STATE 21 CODE >>'.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />$ie tin cite tresis of examination andlor Investigation, In my opt at distil .. ixan
<br />t e dip a date and place and due to the causes) stated. (Signature Mlet
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES PROBABLY
<br />CERTIFIER UNKNOWN
<br />27 TJADAppAttes (Type or Print
<br />Chad Vieth MC 2116 W Faldley #400, Box 9802, Grand Island, = _ _ _ 68803"
<br />25a. HAS ORGAN OR
<br />0 YES
<br />e .TON BEEN CONSIDERED?
<br />ENO
<br />28b. WAS CONSENT GRANTED?
<br />YES.
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 28, 2021
<br />1/24/2022 Item 8a Inpatient To Nursing Home/LTC, Item 8b CHI Health St. Francis To Grand Island Lakeview Care & Rehabilitation Center
<br />
|