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STATE OF NEBRASKA�__�
<br />Hasff2t,.:=e m aririffli Discs>.;;,:z22d5ri9tmi,!, igetYsti P.tts2S, ....,4Trtrrwintt
<br />ry t flit 7"NIS: P ARRiES THE RAISED SEAL OF STATE OF NEBRASKA .IT CERTIFIES THE DOCUMENT BELOW
<br />BEA TRUE COPY"OF<THE ORIGINAL RECORD ON FILE WITH .THE NEBRASKA::: DEPARTMENT OF HEALTH AND
<br />HUMAN SERZVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE f%R ISSUANCE
<br />12 /202
<br />INCOLN, NEBRASKA
<br />202503335
<br />)a A
<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 />CERTIFICATE OF DEATH
<br />.T, QECEOEHTSNAftliE:(Fif'at, Middle, Last, Suffix)
<br />' EGitti N Ish ; Ktttel S r ,
<br />4, STATEOR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br /><;: Grand. isi.a:nd,, Nebraska
<br />. S C1I%f SE I Rnylltiofie #i .
<br />Sb. F)IC WY-$AME (N'ittft
<br />c}7Y 0R TQWN OF; AT'H ()rttttude Zip Code)
<br />,'randd> tslaittl :li33
<br />9a. RE$IDENCE•STATE
<br />Nebraska
<br />''.9d.S REET,AND'NUMBER.
<br />4'00231 ayAve::: r'
<br />:ridrtir►'
<br />13 401M U
<br />(Yen' No, orUnitlYes t)6/21
<br />IbkMETHODdir tEIVE!TION'
<br />Buifgi Oonatign
<br />0"Cram t ❑::Ento.npnlent
<br />C" Ai tsovaic ©t3thsr ($pacify)
<br />and number)
<br />9b. COUNTY
<br />Hall
<br />a; mAiiiiTAc:5TA7tJSAT TIME OF DEATH ® Married 0 Never Married
<br />rr)ed ,Ind separated ❑Wldow.d 0 Divorced ❑ Unknown
<br />AME(First, Middle, Last, Suffix)
<br />:Khan >'; ,
<br />e dates of service If Yes.
<br />54-12/31/1993
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83,.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a.:PLACE OFDEATH
<br />itOS AL::j ' npatient
<br />❑ Eft/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 01189
<br />3, DATE OF DEAt'0,05 , =Y0 . .
<br />Januent2k2020
<br />E. DATE of BIRTT (Mo., n*y, Yr.)
<br />J tI rY2S.
<br />OTHER ❑ Nursing Honte/LTC
<br />® Decedent's Horn
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />lie. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1Db. NAME OF SPOUSE (First; Middle, Last, Suffix) If wife, give in
<br />Judy Rose Anton
<br />12. MOTHER S-NAME (First, Middle, Malden Burn
<br />Gladys ::';;Nash
<br />14a. INFORMANT -NAME
<br />Judy Rose Kittel
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />18b. LICENSE NO.
<br />1495
<br />ltd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />ik::PUNERALAKMa ;:NAME AND MAILING ADDRESS (Street, City or Town, State)::: .: .
<br />i I`Faiihs Furiaral' HDme, 2929 S. Locust Street, Grand Island; Nebraska
<br />CAUSE OF DEATH (See inatructiorts..and examples)
<br />TIE
<br />Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,me
<br />without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Is if necessary.
<br />TE CAUSE:
<br />usa(linia `:;ii i;- land Stage Chronic Obstructive Palrnorriar'y „Dict;:ist3 •
<br />Hitt no
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />TtL PART:d., OTHER;SIGNIFJCAiNT CONDITIONS -Conditions contributing to the dirath::b tt nt t esti ititg. n the'ittrderiying cause given in PART I.
<br />:History'fjf Blsiddew• Derider Status Post Urostomy; Ventral Hernia With<Recurrerit Srttall Bowel Obstruction
<br />IF:EEMAtE <:::.
<br />:Nct pi yn Tit *$It rr pace if.� .
<br />>: Preg ialtat.t lkei oT dUtl
<br />of ontivi tot ie(t bi 42 days Of death
<br />days to 1 pier before death
<br />peetysar
<br />nun/waif::enianienvam
<br />?.. DATEIOFI i3UNY(Iilot;
<br />Idi
<br />I.N
<br />21a. MANNER OF DEATH
<br />El Natural 0 Honticitle.::
<br />0 Accident 0 Pending Investigation .".
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b,:iF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />::.0. Passenger
<br />�*} pedestrian
<br />LJ
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At brme,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />NUMBER, APT.NO. CITY/TOWN
<br />I23e. tyATE OFDEATH (Mo., Day, Yr.)
<br />January26, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Je' :Ill'afv 29. 2020
<br />......
<br />Rti Tc;Hie fissE Of:lriy ktlow4ulge death occurred at the time, date and place
<br />:,, ::and dtisBd,:tbSta1WM(0) stated. (Signature and Title) .. :
<br />rah A, Sakti, APRN
<br />23c. TIME OF DEATH
<br />10:30 AM
<br />USE.CONTRIBUTE TO THE DEATH?
<br />>❑ PROBABLY 0 UNKNOWN
<br />AMI>'ADDRESS OF CERTIFIER (Type or Print
<br />kSakKAPRN, 11207 W Dodge Rd, Omaha, Nebraska, 68154:
<br />1t;c.
<br />Jana
<br />21c. WAS AN AU.
<br />❑ YES
<br />21d. WERE.A
<br />TO OOMPLi
<br />❑ YES:
<br />rat 'street, factory, office building, conpruetiocl
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TEA
<br />Saz
<br />0 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME
<br />a;x
<br />:.':
<br />24e::On tha::Neels of examination and/or Investigation, In ley ,
<br />too tine, dots and place and due to the causNq agMd, @IpllatMrs
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Id,l NO
<br />28b. WAS CONSENT GRA
<br />Not Applicable If 24a hi NO
<br />28b. DATE FILED BY REGISTRAR (
<br />January 31; 2020
<br />,A$AiLABi
<br />o, Day, Yr.)
<br />
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