|
STATE. OF. NEBRASKA
<br />2,Md.Aatwa .. RagttttliAilvtAAr ?" 48 444Yi'AW@Azz : zgrr66Al:'JI(i.i Y•a -
<br />' dell i�41i111111t1�1``
<br />t H %. THIS COPY CARRIES THE RAISED SEAL OF, STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA RtUE COPYOPTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DiPARTMENT OF HEALTH AND
<br />HUMAN SERV/£0, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />F1A7E l?FISSU ; l
<br />6i24/2624
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<br />202403069 ASSISTANT STATE REGISTRAR.
<br />DTMENT OF HEALTH
<br />ANDRHUMAN SERVICES
<br />Ott P. .,.1
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1�ntsapaN1S-NAME First Middle, Last, Suffix)
<br />Iia srirt a Attu''` Cochnar
<br />4 i TY AND`STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />.:: Grand:>Islandx:�l+febraska
<br />fAXICIALSECOSIV
<br />C5.0641477:04
<br />NUMBER
<br />Say AGE - Lae Birthday
<br />(Yrs.)
<br />Ma: FACILITY -NAME (if not institution, give street and number)
<br />C:HI. )j'$•t.:Francis
<br />Be CIT bitiT:01NNrOF:;DEATH (Include Zip Code)
<br />•
<br />Grand ISiand 58803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />tro7T,Arsotkpetiosgs
<br />jPi22tWest Stlt .Str+ieet •
<br />hili. MARITAL STATUS AC TIME OF DEATH 0 Marrled ® Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />&rf
<br />65
<br />UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. Pt,ACE OF DEATH
<br />HOSPITAL kg Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />11: FATHERVNAME PIrst.
<br />441110s Cochnar
<br />Middle, Last, Suffix)
<br />13 EVER (N Us:ARMED FORCES? Give dates of service if Yes.
<br />(Yee, No, or Unk.) No.
<br />16..::METHOD:.CE O)SP.OSITION
<br />SUHal
<br />.::::E(Conation
<br />Cremation Entombment
<br />• Q Removal • p Deter (Specify)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />24 08271:::
<br />3. DA'Z'E OF`.#EAT#I (fLafMlyYr)
<br />June 10 2024 .;
<br />6. DATE OF BIRTH (Ma:
<br />June 5 s 1959 ;.
<br />OTHER ❑!Nursing Home/LTC Q Hospip•.
<br />❑ Decedent's'HaREs
<br />❑ Other (Specify.) •
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE(First, Middle, Last, Suffix) If wife, give then
<br />14a. INFORMANT -NAME
<br />Connie Cochnar
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />12. MOTHER'S -NAME (First, Middle, Maiden
<br />Anna Mae Carkoski
<br />16b. LICENSE NO.
<br />1439
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />.1.?A FUNERAL. Hf E NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ail Faiths Funeral: Home, 2929 S. Locust Street, Grand Island Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />te. 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 insist, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IhIMEDlkrt CUSS
<br />':. diaease:t)r coflditM
<br />S`eeath(
<br />IMMEDIATE CAUSE:
<br />IFrnet a) Acute Hypoxic and Hypercapneic Respiratory. Failure
<br />sasulth,g
<br />aequendally list conditions; if
<br />00.00.s.1f.In.: .the Middl listed
<br />Eatratti UNDERLY1MGCAUSE
<br />(dfsOas or injury Nralinitialod
<br />the events Alluding In death)
<br />LAST
<br />DUE TO, QR AS A CONSEQUENCE OF:
<br />b) Septic Shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />a)
<br />a ,
<br />141. RIiLATItkitNP
<br />Sister
<br />16c. DATt044 t
<br />June 19 +i
<br />1Tb
<br />desB
<br />fik PART li iTHER S1t'aNIFICANT CONDITIONS -Conditions contributing to:the death butnot resulting in the underlying cause given in PART I.
<br />Pulseless i_lectricaI Activity Cardiac Arrest, Nephrolithiasis
<br />MALE
<br />;pregnant ethin W tl year
<br />Ilt tNt
<br />dwltn
<br />Not pregnant, but.pregnent within 42 days of death
<br />' 0 Not pragoant, but pregnant 43 days to 1 year before death
<br />❑ uMmo if Prtgnnnt 101h1-rr tpe last year
<br />2204 GAVE f3F111.44e .(Mo., Day, Yr.)
<br />•
<br />URY AT WORK?
<br />•
<br />YES #a4:
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pendinginyestigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19.
<br />21c. WAS ANAU:Pt I
<br />❑ YES
<br />21d.WEREAUTOPSY °i NGS AV
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YEs`
<br />22c. PLACE OFINJURY-Athome, farm, street, factory, office building, co
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />. OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 10, 2024
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23p. DATESLGNED(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Mine 14 8024 , 02:09 PM
<br />!ytl Tp thsbsbtdfilry turowledge, death occurred at the time, date and place
<br />Gladglky,lclffi�daus (s> Hated. (Signature and Title)
<br />Suresh Manapurem, MD
<br />26:OtD TOS
<br />TE?'
<br />USECONTRIBUTE TO THE DEATH?
<br />NO
<br />0 PROBABLY 0 UNKNOWN
<br />IS
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Pot. On titre Iasis of examination and/or Investigation, in n
<br />s : the time, date and place and due to the cauee(a) e
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO.
<br />427;NAME,'iITLE AND.AGDRESS OF CERTIFIER (Type or Print
<br />Seat sl'i"Mangpurarn, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />26b. WAS CQM$E)
<br />Not Applicable if 264.1:
<br />28b. DATE FILED BY RE
<br />June 20, 2024.,'.
<br />
|