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STATE OF NEBRASKA
<br />-fNE54Tll'eNtN•: esMI arrnm ��� s Slrn )""
<br />u t 1 N.
<br />WHEN TRIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE CORY OR THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />LIM+AN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />!DATE OFISS(1.AIt/c4.
<br />LINCOLN, NEBRASKA
<br />2024011 91
<br />Irl,
<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 />CERTIFICATE OF DEATH
<br />1 DEtEDENTSIAME IFirst, Middle, Last, Suffix)
<br />Stnrartitliirne .Abelbeck
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />.:,.Hebron, Nebraska.
<br />Tsoct SECuRm. NUMBER
<br />506-68-e905
<br />Sc. AGE • Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />Brt CITY OR TOW OF DEATF► (Include Zip Code)
<br />Grsir.Idislart i.: 88803
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />lith' STREETANr3 NUMBER.
<br />5 fid S WO Odle n if DrNe
<br />9b. COUNTY
<br />Hall
<br />10*M tRITAL STATUSAT.TIME OF DEATH ® Married 0 Never Married
<br />0 Marded, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1'#.FA:TER8-NAS.E CFFrsi,: Middle, Last, Suffix)
<br />Ervin iedWirV. AbeeIIbeQk
<br />13. EVER IN tl S; ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or unit.) Yes 04/23/1970-04/16/1973
<br />15. METHOD OF DISPOSITION
<br />❑ obits!{ Donstion
<br />®Gramstlon ;;❑ Entombment
<br />❑ Removal >❑ OnteMIpecify)
<br />72
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PkACEOF DEATH
<br />HOSPITAL ®InpaUant
<br />ER/Outpatient
<br />❑.DOA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 15727
<br />3. DATE oft DEA'T'Ht!.0:: RO,Yr):
<br />November &:2021
<br />6. DATE OF BIRTH ()Ito.,
<br />December 66, 1948
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />lie: APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />18b.NAME OFSPOUSE (Find, Middle, Last, Suffix) if wife, glvs maiden nenti
<br />Michelle Marie McGinnis
<br />12 MOTHER S -NAME (First, Middle, Maiden Surname)
<br />Mabel ! Emma Peters
<br />14a. INFORMANT -NAME
<br />Michelle Marie Abelbeck
<br />180. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d CEMETERY, CREMATORY OR OTHERI.00ATION
<br />Central Nebraska Cremation Services
<br />17.. FUNERAL HOME ton AND MAILING ADDRESS (Street, City or Town, State).
<br />All Faiths Funerai Eithne, 2929 S. Locust Street. Grand Island Nebraska
<br />1Sb. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH:(See €nstructionsand'examples)
<br />1a. PART I. Enter the chitin or even*- .diseases, injuries, or compllationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory sweet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional linos If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEbATEdAuss(FInel <'.a)Failure to Thrive
<br />wiftest or conSticcistilteg._
<br />ln 46 DUE TO, OR AS A CONSEQUENCE OF:
<br />seauentisuy list condition*, a b) Progressive Dementia
<br />any, ei dtgtoatasluesWWI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eme45etiNdrAkt'1N04Ai!#8 €'C)
<br />(dNeaeriflh)m'yttalttnteliit
<br />Ow events resulting M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />IS. PART II OTHE'RSIGNIFICANT CONDITIONS -Conditions contributing to the death but bot resulting in the underlying cause given in PART L
<br />Congestive Heart Failire., Chronic Obstructive Pulmonary Disease, Acute. Encephalopathy
<br />29IF FEMAIM E
<br />NN:t pregnantw atki )nest year
<br />❑ FSYkpnantuamyortlaam
<br />0 NOt prIgnantihot Pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 dayste I year before death
<br />Unknown it preens withiq the past year
<br />220 BATE OFIN URY (Mo.. bay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑.NO::.;:.:
<br />21a. MANNER OF DEATH
<br />® Natural ❑ wemicige
<br />❑ Accident ❑ PeAdhrg lnvestipatlon
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At hoe
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22fL, LOCATION OF INJURY :::STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 8, 2021
<br />CITY/TOWN.',.:'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Nositribetr.11.2021 06:24 PM
<br />234 TO d I best Of 0111knOVilettke, death occurred at the time, date and place
<br />told *MUthe cliup(s) stated. (Signature and Title)
<br />Suresh Manapuram, MD
<br />21b.. IF TRANSPORTATION INJURY
<br />iT. sir itidt3perator '
<br />Passenter
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />'LOBITO.
<br />14b. RELAEOWSfIEP
<br />SPOUSE:
<br />16c. DATE(
<br />November.
<br />DEceet fit
<br />ay,Yr)
<br />2021
<br />Nebraska
<br />1T .
<br />68801;
<br />onset to ;death
<br />onset to dash
<br />19. WAS MEDICAL EXAMINER
<br />OR GORONM R CONTACTED?`
<br />❑ YES ®. NO
<br />21c. WAS AN AUTOPSY PERFORI
<br />❑ YES El NO
<br />D?....•
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO;
<br />DOM, street, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />etc'
<br />24b. TIME OF DEATH.
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUN.CED.PEAD.
<br />245..9n ti bli(*or examination and/or investigation, in my opliion d set twodttsd at
<br />the tied,:Ote and place and due to the cause(s) stated. (Signature amtTltis)
<br />2S DID TOBACCO:USE.CONTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />27 N E iLE DAD EPS OP EERTIFIER (Type or Print
<br />St res#I Mer# apuram., MD, 2620 W Faidley Ave, Grand Island Nebraska,,68803'<
<br />280. REGISTRAR'S SIGNATURE
<br />28a. HAS ORGAN OR TISSU.E;DONATION BEEN CONSIDERED?
<br />❑ YES J NO
<br />its-22%►.8.44-4.en.r
<br />26b. WAS CONSENT GRANTED`
<br />Not Applicable If 28a Is NO C:18 S:
<br />28b. DATE FILED BY REGISTRAR
<br />November 18, 2021
<br />Day, Yr.)
<br />I
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