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<br />STATE OF NEBRASKA
<br />COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO:
<br />BEs A:TRtUE;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 />INCOLN, NEBRASKA
<br />2G25031 1 4? / AI�OHSAs STATE TRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />"TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DECEDENT S 1$E (I llilt,; Midt)lar Last, Suffix)
<br />DEC..
<br />:II tiParelt
<br />4. CITY ANDSTATE OR TEOAT; OR FOREIGN COUNTRY OF BIRTH
<br />.Grand'tstandl. Nebraska
<br />T,'SOCIALSECURITYNU laER.
<br />lb. FACILITY -NAME (If not'lnitltutioil, pIv* street and number)
<br />GHI Health St,-Frncis..HMS
<br />CITY na_toWrr<'O :EA1TFi {Inc
<br />rand Island:.68803"
<br />la RESIDENCE -STATE -
<br />Nebraska
<br />Id.8TREET AND NUMBER.
<br />.291$ W ittlfStreet
<br />p
<br />C
<br />e)
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUSAlTiME OF DEATH ®Married 0 Never Married
<br />0 Married, but separated 0 Wkfowed 0 Divorced 0 Unknown
<br />I t. PATHER•S.NAME (Fir(tt;
<br />Nelson.;
<br />Last, Suffix)
<br />IN: U.S.ARMED'FORCES? Give dates of service if Yes.
<br />No, or Unkj No
<br />16.,METH£] kQF DISPOSITION:.. ,
<br />ti Buil.I .. ❑ l tjaU9rt....
<br />El CreiRatlon' ❑'Entoiribinent
<br />❑Removal'_.❑ Other(Specify)
<br />Sc. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8s. PLACE OF DEATH(
<br />HOSPITAL iclr Inpatient
<br />❑ ER/Outpatient
<br />/ ❑ DOA
<br />IBd. COUNTY OF DEATH
<br />HOURS
<br />MINS.
<br />9c. CITY OR TOWN/
<br />Grand Island
<br />3, 0:Ate OF
<br />February 2
<br />8. DATE OF
<br />October
<br />OTHER 0 Nursing Home1L
<br />❑ Decedent's Home ;
<br />❑ Othor (Specify),
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give m
<br />James E Kasparek
<br />12. MOTHER'S -NAME (First, Middle, Maiden Su
<br />Patricia Kenney
<br />14a. INFORMANT -NAME
<br />James E Kasparek
<br />"ie. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island,City Cemetery
<br />17tt'.FUNBRAI, HOME NAMEAN© MAILING ADDRESS (Street, City or Town, Sty)
<br />A� Faiths.;Funer<al Home, 2929 S: Locust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1439
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examDies)
<br />1a. PART Lester ile chain of events;--titselseh, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />or verdlittiter fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />akAoute on Chronic Respiratory Failure
<br />Sequentially cast condleoret, If
<br />'aril,, baWnp ip 1Ae wds :lfalsd
<br />oq(iltea.. ..
<br />theiNi(iIF tLYI aCAUSE:
<br />xe or rdun, that Initiated
<br />5011 resuiting Pt death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Parainflurza Infection
<br />i78lETO, OR AS A CONSEQUENCE OF:
<br />E)Chronic Obstructive Pulmonary Disease Exacerbation
<br />DUE To, OR AS A CONSEQUENCE OF:
<br />d)Acute on Chronic Heart Failure Exacerbation
<br />RT IL OTHER,SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />ire Malnutrition, t)yuphagia, physical deconditioned. Transition to comfort care and died In the hospital
<br />14b. R
<br />18c. DATE.tMo.
<br />March 4,
<br />19.
<br />OR
<br />❑YE(
<br />20;1:F FSMALE:.
<br />Not.pmgnaM '0hi'(
<br />0 Not pregnant, tnit mynawt jiin 42 days of death
<br />0 Not pregnant, but pregnant 43 flays to 1 year before death
<br />El (hlhnoa* It'pragrlent within the past year
<br />22IL DATEiSF€N sURY4MO , DAY, Tr-)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />210. IF TRANSPORTATION INJURY
<br />❑ Drlvsr/Operator
<br />❑ Paaseogsr
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS. AN AU
<br />❑ YES
<br />21d. WERE
<br />TO CO
<br />❑ YES
<br />22c. PLACE OF INJURY -At horns, farm, street, factory, office building, cone
<br />2211. DSSORIBE HOW INJURY OCCURRED
<br />OF.INJURY STREET! NUMBER, APT.NO. CITYITOWN STATE
<br />, DATE OF DEATH (Mo„ Day, Yr.)
<br />February 28, 2Q28
<br />231), DATE:9ION 1(Mo.; Day, Yr.) 23c. TIME OF DEATH
<br />}�•I'arch. . 6'< 01:08 PM
<br />3d. Tgthe bssi crow knowledge, death occurred at she tan*, date and place
<br />: • And Bietitetile.gitiletlal stated. (signature and Title)
<br />Michael A. Donner, MD
<br />l)SE cONTRtetITE TO THE DEATH?
<br />❑:PROBABLY Q UNKNOWN
<br />AON.0.RS
<br />Icnner M©,
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.11ME
<br />24d. TIME
<br />24e. On the teals of examination endior Inveetgaton, In my eperlontie"'
<br />the thus, date and place and due to the cause(s) stated. flignefula ant;
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 14 NO
<br />FIER (Type or Print
<br />rth Custer Avenue, Grid Island, Nebraska, 68803
<br />26b. WAS COMM
<br />Not Applicable If 28a I
<br />28b. DATE FILED BY
<br />March 12, 2
<br />
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