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<br />STATE OF NEBRASKA
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<br />EN $;>"DOPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS: OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />2/18/2021
<br />LINCOLN, NEBRASKA
<br />202505847- kitot
<br />AAHO�NKA Pdedig,
<br />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 />1.DECEDENr:S4 ..:e„,ipret,• Middle, Last, Suffix)
<br />imothy< Lee td)nger
<br />4 C!TY AND STATE:OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island,: Nebraska
<br />7,:SOCIAL SECURlTY'NUMBER
<br />508:86 5Q17
<br />8E1:'PACI'UTY'41AME'(If not institution, give street and number)
<br />CHI Health St. Francis
<br />Bc: CIV OR. OWN OF>i3EATH (kac(ude Zip Code)
<br />Grand Island 68803
<br />9a: RESIDENCE -STATE
<br />Nebraska
<br />95.kSTR:EET':. 4ND NU . BER
<br />4223 Latriat Pr;
<br />9b. COUNTY
<br />Hall
<br />100; MARITA) STATUS:AT TIME OFDEATH E Married ❑ Never Married.
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1 t F..ATHER;S NAME. (first, Middle, Last, Suffix)
<br />CIVde fedtnoer
<br />13,;EVER IN<U€S ARMS
<br />(Yes, No, or Unk) No
<br />CES? Give dates of service if Yes.
<br />15. METHOD OF DtSPOSrTION
<br />Burial ;; 0 Dofldon
<br />Crean{s pit ( Enio4libm.nt,
<br />Ramowel> ❑Ottjer (Specify(
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />71
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OP DEATH
<br />HOSPITALM Inpatient
<br />❑ ER/Outpadent
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 02060
<br />3. DATE OF egoter '(Mo.(Day; :Y.::C)::;
<br />February 1:1:, 202:1::.
<br />OTHER 0 Nursing Homp/L
<br />❑ Decedsm's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give middennante
<br />Janet Miller
<br />12;'MOTHER''S-NAME (First, Middle, Maiden Surname
<br />Letha. 'Turner
<br />14a. INFORMANT -NAME
<br />Carrie Lynn Franssen
<br />lea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.;FUNERAL.HOME:NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />rtlfi Faiths Funera} Home 2929 S. Locust Street, Grand Island; Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instrelctions.and examples)
<br />it PART 1. Enterthe Chain of.gents-,diseases, injuries, or complicatba4hat directly caused the death. 00 NOT enter tannins! events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />lleiebtATe4eeEffinat ';`: a)Acute Hypoxic And Hypercapneic Respiratory:Failure
<br />dtseaw .04.0fttontasuitltp
<br />ftt.tlos
<br />Sequentially list conditions. If
<br />arty, W ding tothe cause. gated
<br />Ent r she NNOEJtLYI.NG CAUSl
<br />(didea[ae'or kijiiry dtatit!iX'ieted
<br />Ho•splps
<br />it) rC
<br />YES..
<br />14b: RELATIONSHIP TO'D(!
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)..
<br />Februartfi;l.,.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Pulmonary Embolism, Chronic Obstructive Pulmonary Disease Exacerbation, Severe
<br />Sepsis With Septic Shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />ma IWms resualnp in dash) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18.::pART II OCHER SIGNVIFICANT CONDITIONS -Conditions contributing to the des
<br />Acute Systalic Heart' Failure, Acute Kidney Injury, Atrial Fibrillation
<br />20. IF FEMALE:.
<br />(sot pregnant within pnst. year
<br />.' Pregrxntatttmeotdatt;
<br />Not pregnitiit but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />D. t)nknoam.l[pregnent within the past.year
<br />22.1� DATE DF:,i:NJURY'(MO, Day,.Yr.)
<br />22d.INJURY'AT WORK?
<br />YES ...❑NO.
<br />but not resulting in the underlying cause given In PART
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Hoitllcide
<br />0 Accident D. Panding hwestigation,
<br />❑ Suicide ❑ Could not bit dsterminadi
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJUR(
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t".LOCATIONVCINJUI Y STREET & NUMBER, APT.NO.
<br />231'OATEOF DEATH.(Mo., Day, Yr.)
<br />February 11, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Febf idarY :12, 2021
<br />ad T the Brat of :my kn*Wkdgs, death occurred at the time, date and place
<br />arid due e;, 0iisausels) stated. (Signature and Tine) ..
<br />Surest) Manapuram, MD
<br />25. DIp.TOBA4'i
<br />O:USE CONTRIBUTE TO THE DEATH?
<br />NO ❑ PROBABLY 0 UNKNOWN
<br />2T 'NAME, TfT .*. AN. At$ORESE OF CERTIFIER (Type or Print
<br />Suresh Iktanapuram, MD, 2620 W Faidley Ave, Grand island Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />Y yz zJ7 �a /� i� eft
<br />23c. TIME OF DEATH
<br />04:05 PM
<br />21b. IF TRANSPORTATION INJURY
<br />..❑ iAiverloperstor
<br />Q:;Pesssnger
<br />CI Pedestrian
<br />0 Other (Specify)
<br />LIMITS
<br />❑::: No.::
<br />APPROXIMATE INTERVAL
<br />de
<br />19. WA8 M.ED.fe:A4, EXAMINER ''
<br />OR CORONER CONTAC11D2
<br />•
<br />❑YES ''.�NO
<br />21c. WAS AN AUTOPSY.P.ERFORMED? :.
<br />❑ YES ' :111 NO.
<br />21d. WERE AUTOPSY PIND4NGSAVAJLAi
<br />TO COMPLETE :CAUSE OFDEATH?
<br />❑YES ❑NO.. ......
<br />me;:farm, street, factory, office building, constru
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TI
<br />OF DEATH
<br />ODE::::
<br />E
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PR+
<br />24e:On *thesis of examination and/or investigation, fri my epk!ieit ifsapt 4Fxt
<br />the Nine, date and place and due to the. cause(*) stated. feignsture FrJ?3 104),
<br />28a. HAS ORGAN ORTISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />26b. WAS CONSENT G(
<br />Not Applicable If 26a fa M+
<br />28b. DATE FILED 9Y IEG(STRA1t(Mo.,
<br />February 16, 2021
<br />No;;
<br />
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