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STATE OF NEBRASKA
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<br />WiE'N::THI'S COPYCARPJES THE RAISED SEAL OF STATE:O.F':NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />E ATRUE CpPY;OFTHE ORIGINAL RECORD ON FILE Walt THE NEBRASKA :: DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES; `VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />0
<br />DATE `19F ISSUANCE
<br />8/12I2024
<br />LINCOLN, NEBRASKA
<br />202405177
<br />SARAN BOENKA
<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. iDECEDENTS-NAME :{First, Middle, Last, Suffix)
<br />Jennifer jean Pavlik
<br />4:•C(TY..AND:STATE`OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH •
<br />Grand. Island, Nebraska
<br />7SOCIAL SECURITY:(MMBER
<br />507-98-4888'.
<br />5a.'AGE ,Last Birthday
<br />(Yrs.)
<br />eb. FACILITY.NAME Of not Institution, give street and number)
<br />.Neebraska Methodist Hospital
<br />8t? CrrY.ORTOWN.OF'OEATH (include Zip Code)
<br />9a. RESIDENCE -STATE
<br />Nebraska ..
<br />9d STREET*No:NUMB€R
<br />4Q77.Indianheal3:Dr
<br />9b. COUNTY
<br />Hall
<br />10e. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married"
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />115:PATHER`S..NANIE`.'(First, Middle, Last, Suffix)
<br />Jerry JIJ71:<:lanta:'
<br />13; EVER IN,U;S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15...METHOD OF DIS.POSiTION
<br />:❑:Donation
<br />]Crain:titian Entonbment
<br />❑'Rsmovat ❑Other (Specify)
<br />...4:7
<br />5b::UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />81. PLACE:OF DEATH::
<br />HOSPITAL inpatient
<br />❑ ER/Outpatient
<br />❑,coA
<br />9c. CITY OR TOWN
<br />"Grand Island
<br />HOURS
<br />MINS.
<br />3.'DATF
<br />Juhr 22;'2024
<br />6. DATE OF BIRTH {Mu: raw''Yn)
<br />February.. 20;>::1:97:7:
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />Bs. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE(First, Middle, Last, Suffix) Ii wife, give
<br />Russel Pavlik
<br />14a. INFORMANT -NAME
<br />Russel Pavlik
<br />18a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />y 9g ;lNSIDE'GtT :LIMITS
<br />dun name
<br />12, MOTHERS -NAME (First, Middle, Madden Surname
<br />Carol A Findley
<br />16b. LICENSE NO.
<br />1328
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Elmwood Cemetery St. Paul
<br />1Tt:FUNERAL PIQUE NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Jacobsen- reenway-Dietz Funeral Home, 411 0 Street PO Box
<br />12.:::St. Paul, Nebraska
<br />CAUSE OF DEATH (See.instructions and examples)
<br />1$. PART I, Enter the chain of events- .diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arre•st, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes If necessary.
<br />IMMEDIATE CAUSE:
<br />+i lEourzECAnde1orFttU$E fki ; a) acute hypoxic respiratory failure:.
<br />�dtr+sae oy co{su ttflg
<br />In deaiti) .....
<br />Sequentially filet conditMos, if
<br />arfyi:.ludhtg to:tM cruae:.9d ste
<br />oil Enna;:.
<br />::Eneerth.100. R'LlNQ' AUSE
<br />(d .sor infdrythiiiiitisted
<br />the *vents resulting In death)
<br />LAST
<br />S PART IL 1:)THER SIGNI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)septic shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />a)cervical cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ANT CONDITIONS -Conditions contributing
<br />20..IF. FEMALE:
<br />Not:pryln atwll in<pat! year
<br />1442nadt1titnnt.:lijd ith
<br />Ntit pregnant b*A'jirignant whin 42 days of tluth
<br />E3 Not pregnant, but pregnant 43 daye to 1 year before death
<br />EI.LinknateaKerwaranerithin the past year
<br />22d. DATE OF INJURY(Mo.,
<br />22d. INJURY AT WORK?
<br />© YES:....©::A1:Q;:..
<br />Yr.)
<br />the death but not resulting in the underlying cause given In PART 1.
<br />21a. MANNER co DEATH
<br />® Natural . ❑ Holntci,40,:
<br />❑ Accident to t+etidin9 Myestiglitlod
<br />0 (Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22 : LOCATION OF(NJ.URY STREET & NUMBER, APT.NO. CITY1TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 22, 2024
<br />23b,DATE. ;SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />JUIv 26.2024 02:1 PM
<br />22d;T ! ttiovost;Ot:Ny knowledge, death occurred at the time, date and place ,:..
<br />101d 4iN MMok cause($ stated• (Signature and Title)
<br />Ruxana T Sadikot, MD
<br />5 ACCO u
<br />21.b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />IDDPassenger
<br />❑Pedestrian
<br />❑ Omer (Specify)
<br />14b. RELATION
<br />Husband
<br />IP
<br />M. Di4Tff,{tAa.<r>ny, Yr,
<br />,July 27 i2t3Za
<br />DECEDENT'
<br />'1tb::r!,lp t'r(NRi
<br />APPROXIMATE'
<br />Haul's:>;.' .
<br />Oneribto
<br />Montt e:
<br />19. WAS
<br />OR CORONE
<br />YES
<br />21c. WAS AN A
<br />0 YES
<br />21d. WERE AUTOPSY
<br />TO COMPLETE'
<br />❑YES,
<br />-At flume, fa ,:street, factory, office building, con
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />OF
<br />2M:;On thy::liais of examination and/or investigation, in tray 0004n t itlplU
<br />me tithe, date and place and due to tin cause(*) stared (Siei rnif
<br />2 ,:DIQ.T06:...: SE. 26a. HAS O.RGAN.OR TISSUE DONATION:BEEN CONSIDERED?
<br />❑.;YEt3"'::'; NQ ...'❑ ❑ ❑ YES ": :::: Nt1'.
<br />7>, NA1t E' I :: ANDADDRESS OF CERTIFIER (Type or Print
<br />"RutxanaT.Sadikot, MD, 42nd And Emile Street, Omaha, Nebraska; 68198
<br />CONTRIBUTE TO THE DEATH?
<br />PROBABLY UNKNOWN
<br />26b. WAS CONSENT GRAI
<br />Not Applicable if Zit 111 NO
<br />tVAL
<br />OICAL EXAMINEfa ":> ::
<br />CONTACTED?
<br />No
<br />ita tIAttA1 i
<br />:ne..eat.r,y'
<br />28b. DATE FILED BY 'I'RAtk IMo.,
<br />July 31, 2024
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