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<br />STATE OF_NEBRASKA
<br />4yN,,,,: on @CS
<br />s:xCMsds¢nlO
<br />alto''),„ o! .„
<br />WHEN HIS;:COPY-CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE.A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH TfE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />FE 9FISSUANCE
<br />191201.3
<br />LINCOLN, NEBRASKA
<br />202503527 'RAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />00.
<br />;; 1. i3E0E EN1 S44AME .halt, Middle, Last, Suffix)
<br /><):awre ce: Burke:::• Varnes
<br />CERTIFICATE OF DEATH
<br />4. CrtViAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR
<br />(Yrs.)
<br />Los Angeles`Callfornia
<br />#r OCIAL se4101TY_N UMBER
<br />Sb.1 AC(1,r1Y A..(if tot iestib n, give street and number)
<br />CHI:Health St: .;Francis
<br />tic C#iY'aFi' ll1N.OFtiE"AkTHiincludelipCoda)
<br />r . Grand I and k19803
<br />a. RESIDENCE -STATE
<br />Nebraska....
<br />owe*:
<br />IDVi .Road
<br />Ilib. COUNTY
<br />Hall
<br />DEATH ® Married 0 Never Married
<br />owed 0 Divorced ❑ Unknown
<br />1. FA'n1ER S '1AMSftret; Middle, Last, Suffix)
<br />Robert BUrke::>:Verneta
<br />13.gVER IN U.
<br />(Y.", No, or
<br />77
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />6m PLACE :DEATH
<br />HOSPITALlErbieseent
<br />❑ ea/outpatient
<br />. ❑ DOA:
<br />Sc.ICITY OR TOWN
<br />Grand .Island
<br />HOURS MINS.
<br />23:.00286
<br />3. DATE OF DEATH (MO.yiDO; t)
<br />January 9 2 t.
<br />6. DATE Or emTH°(Mo., bays Yr''..)
<br />JanualY2 :19413
<br />OTHER 0 Nursing Hama/LTC
<br />❑ Decadent', Hoar
<br />❑ Other(Spicily)
<br />I6d. COUNTY OF DEATH
<br />Hall
<br />e. APT. NO. St. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai
<br />Kaye Wills Dotson
<br />RMEDFORCEs? Give dates of service if Yes. 114a. INFORMANT -NAME
<br />)No'.
<br />'16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Kaye Wills Varnes
<br />1Z MOTHER'S -NAME (First, Middle, Ma
<br />Frances Luna Mc Waters
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1la.;P(NERALmpsiE:N:sAMR AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Fi neral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />equentially
<br />re
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />aaairt at avenla• dtseeiae, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />r O1rllatien without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional linos if necessary.
<br />IMMEDIATE CAUSE:
<br />+!Acute Hypoxic Respiratory Failure
<br />ns,t b
<br />:gated
<br />OR AEA CONSEQUENCE OF:
<br />'focal Pneumonia end Pulmonary Edema
<br />A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1 PpRrit THER SIQNI jCANTCONDITIONS-Condit ores contributing to the death:bbt not resulting in the:underlying cause given In PART I.
<br />Ohronid )ntE Itial_#'Sato Disease, Acute Delirium, Atrial Fibrillation. -
<br />EtAALE:.: ;..
<br />Not pnstnera;wttith Peet year
<br />Preens'** tlmsnt'fisa.Etf ::
<br />bul;'p syl $ntviellhM 4! deys of death
<br />rgn►nt,N days to 1 year Sabre death
<br />within not peat year
<br />IN 101IY;(Mc Dsy, Yr.)
<br />22d. INJURY AT WORK? �22e. DESC
<br />C1 YES ;:❑ NO::;:.... '
<br />A
<br />21a. MANNER OF DEATH
<br />NI Natural :H.oMiCide .;. ;.
<br />Accident pending *titivation
<br />❑ Suicide ❑ Could not ba determined
<br />22b. TIME OF INJURY
<br />210,;IF TRANSPORTATION INJURY
<br />Dr tr ,Operator
<br />ElPassenger
<br />❑ Pedestrian
<br />❑ Mar (Specify)
<br />14b. REI.A
<br />SO le
<br />21c. WAS AN 'A
<br />❑ Tilt
<br />21d. WERE
<br />TO COMP
<br />❑ YES:
<br />22c. PLACE OF INJURY -At home; farm, street, factory, office building, canst
<br />HOW INJURY OCCURRED
<br />CATION ON IURY;: RTRERrT A NUMBER, APT.NO.
<br />7R OF DEATH (Mo., Day, Yr.)
<br />uarN 9, 2023
<br />23b. DATE SIGNED (Ma , Day, Yr.)
<br />1i a:tia 2023
<br />:(I. �1E.:'It. ;.
<br />t 311; Toby b.stofnly!irnowidge, death °Ccurted et metime, date and place
<br />Sf1 Sueiq:the iwNsl Stated. (Signature and Title)
<br />uresh Manapuram, MD
<br />CITYITOW..N
<br />23c. TIME OF DEATH
<br />09:00 PM
<br />tPBAtCO.Use -CCftTRIaUTE TO THE DEATH?
<br />YES: >;; NE1' ;El PROBABLY ❑ UNKNOWN ❑ YES NO
<br />2TKNAME 'I'ITi :AND:.ABORESS OF CERTIFIER (Type or Print .
<br />Suresh t+#anapurem, MD, 2620 W Faidley Ave, Grand Island Nebraska, 68803
<br />. REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />.:
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUJ
<br />14O. pit ihe:basis of examination and/or Investigation, Witty opinion death ceumd it
<br />the time; date and place and due to the cause(s) slated (Signature tat 'faint)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT
<br />Not Applicable If 28a Is
<br />TBD??.::
<br />❑.
<br />YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 12, 2023
<br />i
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