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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 <br />