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STATE OF NEBRASKA
<br />xdi4i iiiDt tti9riW y aRgiiBIE(la0.Il' sitrrtwntty l
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICE$,"`VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEOF ISSl/APCE
<br />2t7/2fl24`'
<br />LINCOLN, NEBRASKA
<br />b
<br />B:.
<br />U
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<br />at
<br />20240133
<br />3m.
<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 ;DIFCEDEN'CS NAMEj;(First, Middle, Last, Suffix)
<br />trrifl)d 1. Toberl
<br />4. CITY- AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />7 SOCIAL
<br />5,001n100>tittaatiaa
<br />505 52.5959
<br />ha,;AGE -;Last Birthday
<br />(Yrs.)
<br />8b. FACILITY=NAME, (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />Sc;>CITY OR TOWN Qic DEATH (include Zip Code)
<br />Grand (0.00)140)§1.13
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />954STREETAND NUMt:)R
<br />3990 W Capital Auenue
<br />9b. COUNTY
<br />Hall
<br />91
<br />Sb: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />alai: MARITAL:STAT(1S ATTIRE OF DEATH ® Married 0 Never Married
<br />❑ Married, but separati
<br />11, FATHERS NAME :(First,
<br />Henry Toben
<br />Widowed 0 Divorced 0 Unknown
<br />Middle, Last, Suffix)
<br />11 EVER IN U€S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or;Unk.) Yes 05/18/ 954-05/04/1956
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MAo r G(airr .l)
<br />February 4, 2024
<br />6. DATE OF BIRTH
<br />Yr
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (S
<br />Se. APT. NO.
<br />103
<br />9f. ZIP CODE
<br />68803
<br />ASS* CriY1,lAIf1Ta
<br />YES O?NO
<br />'Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden flint.
<br />Marilyn J Schroetlin
<br />14a. INFGRMANT44AME
<br />Laurie Keilwitz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)::
<br />Mar#tla Porth
<br />'S. METHOD OF DlSP031T10N
<br />•Burial •❑oo11ation
<br />;fl Cr*mat)on Entombment
<br />❑Removal: ❑Otlm (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Crystal Wall
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />18b. LICENSE NO.
<br />1561
<br />CITY / TOWN
<br />Doniphan
<br />14b. RELATI
<br />Daughte
<br />16c. DATE (Mss.,
<br />FebruariA9462k
<br />174. Fl?NERA.L.,NOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />..tiYiriaStOdiOaleiAtolland Funeral Home, 1225 N. Elm, Hastings, Nebraska
<br />CAUSE OF DEATH (See lnstruotiofl and examples)
<br />18, PART I. Enter the chem of events- -disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac Artiest,
<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 />lM,eaDlAtB CAUSE Ipinat v a) cardiac arrest
<br />kiaoAtn)
<br />Sequentially list condItions, if
<br />any, Starling to, the cause listed
<br />Fitter the UNDEttt.YlNo CAUSE
<br />(dteeee# or in)ufythatihiffsted
<br />ing in death)
<br />the events reau
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />13) acute coronary syndrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />1Tb,.ZIpt
<br />68901
<br />APPROXIMATE INTERVAL
<br />onset to des'
<br />IDay.
<br />18..PART U OTHER SIGN,t.FICANT CONDITIONS -Conditions contributing tothe death but not resii#ting in the tinderlying cause given In PART I.
<br />thionic kidney disease stage 4; insulin dependent diabetes mellitus, heart failure, advanced age
<br />I. IF FEMALE:
<br />Not pregnntwitinpaat.year
<br />Pregnant at;Woe of death
<br />Nat pregrtant but ptaprant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑_ Unknowni. It pregnant witty tate past year
<br />22d INJURY AT WORK?I
<br />❑ YES ;' ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJU
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF )NJUi Y STREET & NUMBER, APT.NO.
<br />3a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 4, 2024
<br />CITY/TOW
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Februarys, 2024
<br />23c. TIME OF DEATH
<br />04:45 PM
<br />d. Tn'.the best (dryly knowledge, death occurred at the time, date and place
<br />amt due tp tiaitause(s) stated. (Signature and Title)
<br />Srikanth Reddy Kothapalli, MD
<br />25.TOBACCO
<br />DID S USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />. t..l YES J NO . 0 PROBABLY 0 UNKNOWN
<br />21p::IF. TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Peaeenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />Y At home,
<br />19- WAS MEDtCAI .EXAMINER
<br />OR CORONER CONTACTED?
<br />lJ YE$ ❑ NQ
<br />21c. WAS AN AUTO
<br />0 YES
<br />tED?'
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES p'..Mti.......' .. .
<br />rrt, street, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b."
<br />Tit
<br />CODE'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUN
<br />14e.pif.thttbasis of examination and/or investigation, In my opinion death atjcurnd at
<br />"tile tkne, date and place and due to the
<br />causspl stated. 18ignature:aild 311b)'
<br />❑ YES El NO
<br />27 NAME, TITLE AND ADDRESS Sd CERTIFIER (Type or Print
<br />Sflkanth Reddy. Kothapalli, MD, 2620 W Faidley Ave, Grand (stand, Nebraska, 68803
<br />284. REGISTRAR'S SIGNATURE
<br />nidi 6:144..4,e? A014.14
<br />26b. WAS CONSENT GRANTS
<br />Not Applicable if 26a Is NO ....
<br />28b. DATE FILED BY REGISTRA
<br />February 6, 2024,
<br />❑ NO
<br />(Mo., Day, Yr.)
<br />CD
<br />U,
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