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<br />STATE OF NEBRASKA _ >
<br />I�d'�E e59�d,N°t° i��.e4917W1(IWPhu. 9rht°�NdAas _„_ �._. ___..._.._.�.�.
<br />((((61Jdo°«e.10
<br />i%6ii101/4/1111\�0
<br />WHEN THIS COPY CA014- ES THE RAISED SEAL OF STATE OFNEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEATRUE CORY OF THE 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 />DATE OF ISSUANCE
<br />8/412028
<br />LINCOLN, NEBRASKA
<br />202401008
<br />SARAH BO1INENKAMP``
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />DECEDENT!$•p1AME :(First, Middle, Last, Suffix)
<br />E)eanoral < M ;.Ee)lke
<br />E
<br />CERTIFICATE OF DEATH
<br />LTYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7.8OCIA14SECURrTY NUMBER
<br />506 50'-7'73
<br />8b. FACILITY -NAME (It not institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. CITY OR TONIN OF DEATH (include Zip Code)
<br />Grand lslaitd 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d ,$7REETANDNUMBER
<br />114205 I titltot Road
<br />9b. COUNTY
<br />Hall
<br />10a. MARITALSTATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ria Widowed 0 Divorced 0 Unknown
<br />11 FA.THER'S-N AME (First, Middle, Last, Suffix)
<br />Edwafd Swanson
<br />13 EVERIN U:S ARMED:FORCES?'
<br />(Yes, No, or Unk.) No
<br />METHOD OP DISPO51110N
<br />p<eutla)p Danetton
<br />Itt;Cremetlotz 0Entantbment
<br />❑`Removat ❑ OUter (Specify)
<br />ive dates of service 11 Yes.
<br />Ba. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />'Bb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Bc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL lod Inpatient
<br />[] ERIOu patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH.(Mf>ti Day,"
<br />July 28, 2028
<br />8. DATE OF BIRTH (Mo., Day, Yr:)
<br />January 27
<br />OTHER 0 Nursing Home/LTC
<br />El Decedent's Ho
<br />❑ Other (Specify
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />1017. NAME OF SPOUSE (P&st, Middle, Last, Suffix) If wife, g
<br />Daryl Beilke
<br />1*INSIDE. MI*0$
<br />i Q YE6 No
<br />maiden nes
<br />12. MOTIER'S.NAME (First, Middle, Maiden Surname)
<br />Sophie Erickson
<br />14a. INFORMANT -NAME
<br />Joseph Grabowski
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />A>Ifel Funeral Mame, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b. RELATIONSHIP TO DECED
<br />Power of Attorney
<br />18c. DATE (Mo, Daly, Yr )
<br />July 31, 21}23..
<br />STATE
<br />Nebraska
<br />te, PART I. Enter the cheln of events- -damages, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />Wltii6DtA CAuSE(Ftnat a)Sepsis and pneumonia
<br />owes.or condition rssuklnp::
<br />tle#Ilt.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions,. it b)
<br />anylin; tesding to tire. cause ectad.
<br />krt o .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />CAUSE 0)
<br />(dis aSO dr Injufjj thatinak
<br />the events resulting in des
<br />LAST
<br />1)
<br />18. PART i(..OTNER SIGNIFIC
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />T CONDITIONS -Conditions contributing to the death
<br />20. IF.FEMALE:
<br />n Net pre9nantaShih peat ys
<br />q
<br />Prs9°MIlt Ot lime Or death
<br />M.et.pngmt,l Out pregnant within 42 days of death
<br />0 Not pregnanR. but pregnant 43 dura to 1 year before death
<br />:Unknown I1.p»gnant wahin the pain year
<br />22e ::BATE OF ffiJURY Hilo„
<br />22d. INJURY ATWORK?
<br />❑ YES ❑ NO
<br />CATION OF
<br />JU8'
<br />22e. DE
<br />TR
<br />21a. MANNER 0.F DEATH
<br />® Natural ❑ Npmfeide
<br />o Accident ❑ f+mnddhg Irtvestigaifon
<br />❑ 8ulcide ❑ Cotdd not be debrminod
<br />suiting In the underlying cause given In PART 1
<br />22b. TIME OF INJURY
<br />21b IF TRANSPORTATION
<br />❑ DdvarlOperator
<br />0 Pessehger
<br />0. t des tan
<br />0 Other (Specify)
<br />INJURY
<br />18, WAS MEt 10AI:EXAMINER
<br />OR CORE R P NTACTEG?'
<br />❑ YES, . �'NQ
<br />21c. WAS AN AUTOPSY P
<br />❑ YES ria NO , ...
<br />21d. WERE AUTOPSY Pt$DING1
<br />To COMPLETE CAUSE OP
<br />❑ YES Q, NO
<br />22e. PLACE OF INJURY..At home, Awn, street, factory, office building,
<br />RISE HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />DEATH (Mo., Day, Yr.)
<br />July 28, 2023
<br />CITY/TOWN.
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />.Iilltl 294:123 12:33 PM
<br />Tobei Wet et my knowadge, death occurred at the time, date and pace
<br />#$u uO #Ad! Causes) stated. (Signature and Tale)
<br />Ret ria Ramakrishnan DO
<br />z
<br />28. DID TOBACCO USE C,ONIRIBUTE TO THE DEATH?
<br />BLE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ZIP.
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH '
<br />24d. TIME PI
<br />24a. Ojf the breis of examination and/or investigation, In my opimttOdes t 040W5ad at '
<br />the flees, date and place and dun to the cause(s) Mated. (Slgnettce *RAPIN)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />q YES :� NO PROBABLY ❑UNKNOWN`
<br />0 YES NO
<br />7 NAME, TITLE 4. NDADDRESS OF CERTIFIER (Type or Flint)
<br />Reena R makrtshnan, DO, 3533 Prarieview St, Grand Island, Nebraska, 68803'
<br />REGISTRAR'S SIGNATURE
<br />.4.4444-43,1
<br />26b. WAS CONSENT'GF
<br />Not Applicable if 26a is Nt
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 1, 2023
<br />
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