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rrrrlA� _.. STATE O.F.. NEBRASKA
<br />lihMddax x+gttt@7�.QtO��e°x asahMhWdddXaa - a+8BG6Fl.Ir�ItltAYxts, irrhUprdara
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<br />HF�ti) `HIS ft}I 1r aA` RI>'tES THE RAISED SEAL OF STATE OF NEBRASKA, tT CERTIFIES THE DOCUMENT BELO
<br />A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />>DECEDENTS
<br />)Shona :Leen:;:. Miller,
<br />202404563
<br />SARAHBOHNENKA:
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />le, Last, Suffix)
<br />2. SEX
<br />Female
<br />340
<br />3. DATE OF 1IElt1
<br />Auauet
<br />4:01T5 AND STATE'OR, TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />„Rural Chase CQurjty, Nebraska
<br />} .SOCtA1. SECURITY NUMBER
<br />5Q� 32 l$4
<br />Si; AGE - Last Birthday
<br />(Yrs.)
<br />93
<br />su..MOR,ITY-RAtAt (If not institution, give street and number)
<br />COed SOMaritan: Society -Crane Meadows
<br />Sc 'CITY O TI `OF DEATH (Include Zip Code)
<br />Grand lsi#nd::=.;88803 •
<br />9e. RESIDENCE4sTATE
<br />.Nebraska:.
<br />• .:*TrOFF.: Alt -t.#1 t
<br />>407VTi►r erlt:n:.e::Street
<br />t0a 'MARITAj Sti1T(18 AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married; but separated ❑-Widowed El Divorced 0 Unknown
<br />613. UNDER 1 YEAR
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATI:f.
<br />HOSPITAL. ❑,;Inpatient
<br />❑ ER/Outpatient
<br />❑DOA
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify) ASSISTED I�)VFN(I
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand:. Island
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />tie(
<br />Yd
<br />10b. NAME OF SPOUSE(First, Middle, Last, Suffix) if wife, give'
<br />} :PATH#=14 SLA(ISE (F)ret, Middle, Last, Suffix)
<br />•
<br />loseot ' BaleV
<br />13, EVER IN U S ARIMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unk.}No
<br />14001'tIOG::QF OI:SP:.OS.ITtON
<br />ealttn
<br />40400.,
<br />Gremt;wtf#t ❑ EntOntbment
<br />0'a r ; ClDiertst»elfy1
<br />1Zq;,riINE14Ai HO(k NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />LFII
<br />OftfiCPotoeat Home, 2929 S. Locust Street, Grand Island,. Nebraska.
<br />(12. MOTHER'S -NAME (First, Middle, MaldenSu
<br />Zella Harris
<br />14a. INFORMANT -NAME
<br />Valerie Galvan
<br />18a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions' and examples)
<br />1a. 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 />reapiattdyarrest .arventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a)Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />segue nhtgypst coed Norge, if b) Cerebrovascular disease
<br />tiil>r;101yinpt OtIcta Fl i tea
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />rf 3h«t+tip I Y161tOMME C)Iatrial fibrillation
<br />(dlaiiise or 1444th 'initiated
<br />the rowddrlg in Meth) DUE TO, OR AS A CONSEQUENCE OF:
<br />j Ast
<br />4)
<br />l9:PAR711.
<br />ESE
<br />NIFICANT CONDITIONS -Conditions contributing to the death but net recUIti
<br />in 42 days of death
<br />U Not Proaaint, but'Pfagnint wit e
<br />0 Not Praynant, bltpreg snt43 drys to 1 year before death
<br />thdet4wa11'_jtraBNtlgtl, Mer+n, Tpfe peer
<br />eta 00t.4 F.r (Me:; iffy; Yi.)
<br />21a. MANNER OF DEATN
<br />El Natural ❑Homicide
<br />❑ Accident ❑ Pending inveettgatlon
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />Ab RELATIONSIEPTt9D
<br />Daughter
<br />1tic DATE(Ma,.. ,Yt).....
<br />Auoust
<br />YE
<br />daaet..
<br />r
<br />in
<br />in the underlying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />0 Ortver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />9.
<br />21e. WAS AN
<br />❑ YES
<br />21d. WERE AOT
<br />❑AYES
<br />22c. PLAOE OF INJURY.At homo, €arm, Street, factory, office building,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />SCSI STREETS NUMBER, APT.NO.
<br />OF DEATH (Mo., Day, Yr.)
<br />August 9 5; 2024
<br />(Mo., Day, Yr.)
<br />LjL1{T..'429 09:27 PM
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />t+ff My edge, death occurred at the time, date and place
<br />ttt ft ths'civae(s) stated. (Signature and ml.)
<br />Jennifer L. Brown, MD
<br />Cf OBA p Q1.!EtC.PNIRIEUTE TO THE DEATH?
<br />O ';:❑ PROBABLY 0 UNKNOWN
<br />DAIDRESE 6F CERTIFIEft(Type or Print
<br />ifr" $iyirla MO, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />ts
<br />'b
<br />§
<br />ISSUE D
<br />6d +
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />aG
<br />244.On the basis of examination and/or investigation, in in;
<br />th4 time, date and place end due to the ause(s) su
<br />TION: BEEN CONSIDERED?
<br />REGISTRAR'S SIGNATURE
<br />25b. WAS
<br />Not Applicable If 2$ar
<br />28b. DATE FILED
<br />August 22,
<br />2
<br />
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