|
STATE OF NEBRASKA
<br />,,,A911IDtttOT
<br />IIYTE GC►Py'.r RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />RI3IPIAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND `N
<br />MA li SERVICES, VIALRECORDSOFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />2-0 2 5 0 5 3 35 ' A AH B/54
<br />OHNENICA} MP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT O' HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />ast, Suffix)
<br />AND t'TATE`OR TAT*t Y, O R FOREIGN COUNTRY OF BIRTH
<br />erner::< ebras!'::>:::.;'..
<br />t�IraltRtrdon give street and number)
<br />It H (tlt,✓t., F I:nci
<br />r f. t�RTL1YVltf;tItl4tuds Zip Code)
<br />Rrtd'':l slantt':'
<br />iDENCE $TAT
<br />MARITAL $TM AT'
<br />M*r rled, bell sspar$t
<br />FAlHivft!S•NArttE tF)Fal
<br />914.000NTY
<br />mall
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />tH 0 Married 0 Never Married
<br />NM 0 Divorced 0 Unknown —
<br />Last, Suffix)
<br />3b. UNDER 1 YEAR
<br />a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />Sc. CITY OR TOWN
<br />Grand Is
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />OTHER 0 Nursing HointILTC.;
<br />❑ Decedent's Hater :v
<br />❑ Other (Specify) ..
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) WWfe, give madden
<br />14a. INFORMANT -NAME
<br />Jacey McGowan
<br />to FUNERAL DIRECTOR SIGNATURE
<br />Daniel D Naranjo
<br />. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Iestlawn Memorial Park Cemetery
<br />SAS Mli1 RAD MAILING ADDRESS (Street, City or Town, State)
<br />t erwl,.,F otne 2929 S. Locust Street, Grand Island, Nebraska
<br />s�ase}, in caries, or complications.hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />12. MOTHER'$•NAME (First, Middle, Maiden
<br />Ed II Benson
<br />16b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />rNNlapn wjthout showing the etiology. DO NOT ABBREVIATE. Enter only one cases on a line. Add additional lints if necessary.
<br />IEDIATM CADS(
<br />Severe Sepsis
<br />�TQ,ORASACONSEQUENCE OF:
<br />_tfmatoid arthritis
<br />ti AS A CONSEQUENCE OF:
<br />Renal Failure
<br />SIR AS A CONSEQUENCE OF:
<br />i+re Urethritis
<br />A 1.li..:trMeR: tGlNi t At t' ONDITIO
<br />ittll+t�r;lfatti:;<:;.
<br />Ali
<br />T
<br />:LC9Rr`ATnoi CF i
<br />a. OATS O
<br />Au8U1
<br />DATES
<br />To
<br />YR
<br />S-Conditions contributing to the death but not r
<br />thin 42 days of death
<br />40 Says to 1 year before death
<br />Year
<br />y
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homii;ide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />Ring In the underlying cruse given in PART I.
<br />14b.#RISt.A
<br />Iugi
<br />❑ vet`:
<br />21b. IF TRANSPORTATION INJURY 21e. WAS AN YPERFO
<br />© Driver/Operator 0 Passenger ❑ YES
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE A
<br />TO COMPL
<br />0 YES
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, cons
<br />E HOW INJURY OCCURRED
<br />BEETS NUMBER, APT.NO. CITY/TOWN
<br />2O
<br />Gati1
<br />DOn0e
<br />MI6 7114 AAI :'ACIbI
<br />tilleI A. fltti finer,
<br />ATu1#E
<br />ay, Yr.)
<br />y, Yr.)
<br />23c. TIME OF DEATH
<br />09:24 AM
<br />occurred at the time, date and place
<br />;anattire and Title)
<br />DEATH?
<br />BLY UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OP IMtA
<br />24d. TIME P
<br />24e. On the battle of examination and/or investigation, in
<br />the time, date and place and due to the causela) stated. (at
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />❑ YES ®NO
<br />iF CERTIFIER (Type or Print
<br />729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />4c �a_� Bss��c�,•rr►�
<br />26b. WAS CONSENT
<br />Not Applicable if 264
<br />26b. DATE FILED BY RE
<br />September 2, 2028
<br />
|