2S Dip: TOSACC0 USE:. GON;TRIBUTE TO THE DEATH?
<br />II� YES NO :iPROBABLY 0 UNKNOWN
<br />7P. NAND *tilt :ANDADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />2i
<br />REGISTRAR'S SIGNATURE
<br />• t
<br />t2iJ �a>rrzrlc
<br />i y ib;, f,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CEFi7'II=IES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY 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 />ATE OF;tSS&IANC'E
<br />1 /272025
<br />LINCOLN, NEBRASKA
<br />20250.0677 l.y /344.444
<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 />i REi.`.EDI»NTS-NAME (First, Middle, Last, Suffix)
<br />Loretta ,Tune Dawkins
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Geenit.islarid, Nebraska
<br />SQCIAL SECURITY NUMBER
<br />•
<br />608 80 0375
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />4.193 Norseman Avenue
<br />sc. Ct1Y OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />72
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA:
<br />HOURS
<br />MINS.
<br />2110521
<br />3. DATE OF DEATH (Mo., Day Yr)::
<br />August 10, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 9, 1949 .
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />❑ elospiee:Facfity
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREETAN0NUM18ER:::.
<br />41::93 Nortietnan Avenue
<br />9b.000NTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH RI Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERS NAME (First,:':, Middle, Last, Suffix)
<br />Jaynes Minor
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />18 ME'THQD,OF. DISPOSIT'1oN
<br />©.lieuriai ] oonattpn
<br />IRi Cremation; Erttonibment
<br />❑ Removal ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />. Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />gg lNalbE.cn-Y (I M[ITS"
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Robert Dawkins
<br />14a. INFORMANT -NAME
<br />Robert Dawkins
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S*NAME (First, Middle, Malden Surname)
<br />Jean . Larson
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18c. DATE (Mo, Day. Yr.).''
<br />August 11 2021
<br />STATE
<br />Nebraska,
<br />17a FUNERAL HOME NAME.AND MA LING ADDRESS (Street, City or Town; State)
<br />Apfel Funera► Home:'1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART1. Enter the chain of events. diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />aspiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause anti Ilse. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />(MMEDFATEOAUSE(F1141s>:a)CHF
<br />aisoo orcondN;onosogop
<br />In death)
<br />Seguenhally, Ilst conditions If.
<br />„ally, Ie ding to the fieuse hated
<br />Entei'tlir<UNDERf YINt3 CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />8. MAT 11 OTHER SIGNIF
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)COPD
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)COR Pulmonale
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Moderate Protein Calorie Malnutrition
<br />ANT CONDITIONS -Conditions contributing to the.death but not resulting in
<br />25.IF:E.EMALE "'
<br />tai:N.ai preghant.wdttiapaat ygat
<br />❑ i!'regtt*3f at tiirid of draih , :::.
<br />❑ Net pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pre9nant43 days to 1 year before death
<br />. itriknown N prugnam withlrl;the past year
<br />TE:
<br />INJURY (MO, Dey, Yr.)
<br />22d. INJURY AT WORK?
<br />(pYEaNO
<br />22f. LOCA
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Inv.'stigedon
<br />❑ SulCide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />'underlying cause given in PART 1.
<br />21b. IF TRANSPORTATION
<br />Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />1710ZIP::Oodet'
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Unknown
<br />onset to death
<br />onset to,dtiath
<br />onsetto..:deeth.
<br />19. WAS MEDICAL EXAMINER"
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?'";;:
<br />❑ YES Igi NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Egad
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />N OF INJURY:: STREET & NUMBER, APT.NO.
<br />cITV/TowN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 10, 2021
<br />2Ib«-DATE STONED (Mo„ Day, Yr.) 23c. TIME OF DEATH
<br />AUQUISt 11 :!2021 09:07 AM
<br />23t4,7000aturmy?k, howledge, death occurred at the time, date and place
<br />and>dus to,:thti alias;Ns) stared. (signature and Title)
<br />Chad Vieth, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCE
<br />P CODE.:,;
<br />EAQ:
<br />24e:.On thous is of examination and/or investigation, in my opinion death aauired at
<br />the time, ate and place and due to the cause(s) stated. (Signature and TNM)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />•
<br />28b, WAS CONSENTGRANTED?
<br />Not Applicable if 26a is NO D YES
<br />28b. DATE FILED BY REGISTRAR..(NIo., Oey, Yr.)::;;,;.
<br />August 13, 2021
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