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<br />STATE OF NEBRASKA
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<br />iWHEN<THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, iT CERTIFIES THE DOCUMENT BELOW TO
<br />EIE A TRUCOP
<br />EY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/3Q/2b��
<br />LINCOLN, NEBRASKA
<br />202402557
<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 />1. CECEDENI$ NAME: (FIrst, Middle, Last, Suffix)
<br />Annette # M Ellington
<br />CERTIFICATE OF DEATH
<br />4.;CITYANDTATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />608-64-2793
<br />5s -.::AGE - Last Birthtisy.
<br />(Yrs.)
<br />8b FACILITYrNAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />Sc ;CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />Ba. RESIDENCE
<br />Nebraska
<br />TATE
<br />Set STREET AND NUMBER
<br />11 Ponderosa Drive
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6d. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE Oa DEATH•
<br />HOSPITAL Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />10a'3 MARITAL:STA'TIIS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHER'SAll (First, Middle, Last, Suffix)
<br />•
<br />Howard >Eafi Tibbs
<br />13;::EVER IN U;S. ARMED" FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />15. M£THOD,OF DISPOSITION
<br />BuriOi QOotlation
<br />114 Cremation Q Entombment
<br />d Removals; ©Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF Wok.*
<br />May 20 2024
<br />S. DATE OF..BIRTH (Mo Days Yr.?
<br />July 14,
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Hon
<br />❑ Other (Sp
<br />led. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE' (First, Middle, Last, Suffix) If wife,
<br />Robert Ellington
<br />14a. INFORMANT -NAME
<br />Robert Ellington
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12Eulalla MOTHERS NAME (First,
<br />ary Bigiev Middle, Maiden Sumam
<br />M
<br />16d. CEMETERY, CREMATORY OR OT#ICR LOCATION
<br />Central Nebraska Cremation Services
<br />17a FUNERAL'HOME:NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths€Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (Seeinstructlons and examples)
<br />REL
<br />rOU
<br />TIC
<br />DATE {Mo„ qa
<br />Mav 23 .2024.'
<br />NT.
<br />111. PART I. Enter the chain of events- diseases, 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 one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />Poe EDIAnncoues(Finai a)Acute on Chronic Respiratory Failure
<br />disease es common resulting
<br />in deaf) DUE' TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)Small Bowel Obstruction
<br />any, leading to the cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />15niarthe UND tLYINGCAUSE c) Chronic Obstructive Pulmonary Disease
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Physical Deconditioning
<br />APPROXIMATE II
<br />to deal
<br />iS..PART II OTHER S(GNIFiCANT CONDITIONS -Conditions contributing to the death Ifut nett resulting in theunderiying cause given in PART L
<br />Comfort Care
<br />20. Ip FEMALE;..
<br />Notpregneitf within paslyear
<br />Pregnant atdme df rkaih
<br />1:1,Notot.gn*ni butpregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ unknownitpregnartwithinthepestyear:
<br />22. PATE.INJURY (Mo., Day, Yr.)
<br />22d.INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homkids
<br />❑ Accident ❑ PendingIdvestigeb
<br />❑ Suicide ❑ COuld not be &terminad
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ .Pedeetrien
<br />❑ Other (Specify)
<br />21e. WAS ANA?
<br />0 YES
<br />21d. WERE AUTQPSY #1(
<br />TO COMPLETE CAU
<br />❑ YES -�
<br />22c. PLACE OF INJURY -At home, farm„.street, factory, office building, construction
<br />22ee. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INAIRV STREETS NUMBER, APT.NO.
<br />e
<br />0..
<br />23a.`DATE OF DEATH (MO., Day, Yr.)
<br />May 20, 2024
<br />CITY/TOWN
<br />23b. DATE SiGNED (Mo., Day, Yr.)
<br />Mev 24 2024
<br />23c. TIME OF DEATH
<br />08:35 AM
<br />3d Te tits kat of i ty knowledge, death occurred at the time, date and place
<br />sad due tO the: causes) stated. (Signature and Title)
<br />Michael A, Donner, MD
<br />sAY
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />• 20d, TIME PRONOUNCED DEAD
<br />24e: Oil the Oasis of examination and/or investigation, In my opinion eosin
<br />shit time date and place and due to the cause(s) motet (Signature #n,)
<br />DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES [� NO :>❑ PROBABLY ❑UNKNOWN
<br />0 YES NO
<br />27, NAME, Ti'fl AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska,68803'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE
<br />280. REGISTRAR'S SIGNATURE
<br />ov--rami
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO Qys •
<br />[ ►)1
<br />26b. DATE FILED BY REGISTRAI
<br />May 28, 2024
<br />0., Day, Yr.')
<br />
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