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<br />MOP' COPY CARRIES THE RAISED •SEAL OF THE: STATE OF NEBRASKA, • IIT.
<br />CERTifIESlifitHE DOCUMENT BELOW TO BE .A TRUE' COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />Rj' coopS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITTAL RECORDS
<br />{TE OF ISSUANCE
<br />11/16/2020
<br />LINCOLN NEBRASKA
<br />2024019
<br />7.kei.,
<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. AlMO N- NAME (E ret Midtgs, Last, Suffix)
<br />Cobert Haft Pollock
<br />4. CITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL sECURrrY NUMEIER
<br />008--0835.
<br />5a. AGE - Lala
<br />(Yrs.)
<br />77
<br />fib: FACILITY -NAME (If flim Msttud
<br />C.H1.Health St. Francis
<br />give strest'end number)
<br />Biathdary
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2015406
<br />3. DATE OF DETtt;(iiilb,;
<br />October29, 2020,;
<br />6. DATE OF BtRTH(Mo.,'Day Yfr )
<br />December:3,1.942 ..,..
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ' (_l Hoeplce Fatuity
<br />• Q ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other (SpecKy)
<br />Sc t rry OR TOWN OF' D£tATH (Include Zip Code)
<br />Grand 151aitd<: >68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d S7`R E.T 4NO NUM R£a •
<br />. 2750 St .Paul.do(ad=
<br />9b. COUNTY
<br />Hall
<br />Ida .MARfTALSTATUS:IAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Wdowed 0 Divorced 0 Unknown
<br />11 BATHERiifAM:B (First, • Middle, Last, Suffix)
<br />Fred G Pollt7ck
<br />13':iERiN U S Aitll#OFORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />®<IBurial Qoorm#ton
<br />Q Cremstlon,
<br />0Entettlbriterit
<br />❑Removal. <QOEher(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />FGlS1D!»:t STY M1;1S.;
<br />.YES ❑: tit
<br />10b. NAME OF SPOUSE (First;Middle, Last, Suffix) if wife, give maiden male.:
<br />Jean Falldorf
<br />112. MOTHER'S -NAME (First Middle, Maiden Surname)
<br />14a. INFORMANT -NAME'
<br />Jean Pollock
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />Antonia B Plath
<br />16b. LICENSE NO.
<br />1448
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a,.FUNERAL .HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral. Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />ta. PART!. Enter the chile of events- d *eu,s, injures, or compfcatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />mspkatoty Mast, or ventricular fibntntbn without *flowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if nese
<br />IMMEDIATE CAUSE:
<br />IMI A7rE cAUse Ialh,a a) Cardiac Arrest
<br />*0.ss er Cold*N4rt redU *lp
<br />deldt0.::
<br />Sequentially list conditions, If
<br />any.ItridIng tothe1111M0 fisted
<br />enema a
<br />Enter the.UNDERLYIN6.DAt18E
<br />(dlaesse or iryu y.that tidttated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Diabetes Type 11
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)Hyperlipidemia
<br />14b. RELATI
<br />Wife
<br />IP TOOECSOEt±iT.
<br />16c. DATE.(Me., Day, Yr.)...:..
<br />Novemb$r 6, !024
<br />1S PART II O#HER SlG1YIFIcANT CONDITIONS -Conditions contributing to:the death but na(:resutting in the Underlying cause given in PART 1.
<br />Pattern Fasted U gier'The Care Of ER Physician And Arrived In Active Code. ER MD Documented Cardiac Arrest As Diagnosis.
<br />20. IP EMAJE;,:.
<br />iNdtprrgnantankltin.past:year _
<br />Protrnani*Ort*oidesttt
<br />�fiiot p»{puaiK bUl ptpptunt Within 42 daye of death
<br />• Q Not pregnant, but pregnant 43 days to 1 year before death
<br />Unanown lfpregnan Matin are peat year
<br />22aDATE Qtr INJURY (Mo:; Day: Yr.) .
<br />22d. INJURY At' WORK?
<br />❑YES_ ONO.
<br />221. LOCATI
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />0 DrivenOperator
<br />QPa:manger
<br />0 -Pedestrian
<br />❑ Other (specify)
<br />TA'E.
<br />Nebraska
<br />1168b. Zi80p, 1Code . .
<br />APPROXIMATE INTERVAL
<br />onsettO deet//
<br />immediate
<br />*fleet to death
<br />Years.
<br />oromicooxfil
<br />: Years
<br />onset to death
<br />Years
<br />i9. WAS' MEI is AL EXAMINER
<br />OR CORON CONTAGTED7 ,':
<br />❑ YES 1Zj
<br />21c. WAS AN AU
<br />❑ YES
<br />21d. WERE AUTOPSYANDINGSMVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES O.NO...
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction ette(ifilS,.t
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY.': STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 29, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />NfiveMber::11.2020
<br />23c. TIME OF DEATH
<br />09:21 AM
<br />d ro;lba #,est of lift' knoaiedge, death occurred at the time, date and place
<br />trill duelo ttiecawa(s) stated. (Signature eed Title)
<br />Mtchael A. Donner, MD
<br />Hh
<br />.
<br />STATE
<br />244:DATE SIGNED (Mo., Day, Yr.)
<br />24b.11
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d.
<br />OF DEATH
<br />24e. On the basis of examination and/or investigation,In my optnlpn dsiath.acci+rtei# at
<br />Mettle, date and place and due to the comets) stated. (?N9rlokns and 1ltiel :.
<br />2S. 0.D: TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YEs ;IJ NO ❑ PROBABLY 0 UNKNOWN
<br />27:0000.:(4AND ADDREsk OF CERTIFIEI4 (Type or Print
<br />tlClliatri :4i Do.iier, MD, 729 North Custer Avenue, Grand island, Nebraska, 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES IJ NO
<br />)Est 'z2.,A
<br />26b. WAS CONSENT GRANTED....
<br />Not Applicable N 2$a is NO
<br />28b. DATE FILED BY REG!SitRAR (Mo., D
<br />November 12 2020
<br />.A3
<br />N)
<br />
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