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STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.1IME OF DEATH
<br />.. 34a. 4n:ihe basis of examination andtor investigation, in ray **ten d. t otsurtedXit
<br />ths:thne; date and place and due to the cause(s) stated. (signature. nd llki) � .::.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®:.NO:
<br />braska, 68124:
<br />STATE OF NEBRASKA
<br />•?Crrrrrrl+FF3,e� c:.eq`;uld,1,111A10PFxx:c:>_,soti�MiY�WOa�a,$:.. 44.I,i�:1%P.N1yFn>.,.,�,; ;av rr mr¢�� t iStir l"�pg •.1,1, 3� .q .9 �i44irlii�'it
<br />x4R66 AdhuSu ��� ��d.�%h7���Y1i1/i�F2�?.'�%'%�•EI,.hM��. be.:
<br />01111111Plos, -po7;°
<br />WHEN THIS COPY CARIES THE RAISED SEAL OF STATE OF NEBRASKA, ircErinnEs THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />i)aOFISSLIANOE
<br />LINCOLN, NEBRASKA
<br />DE ! efirs:NAME ,(First, Middle, Last, Suffix)
<br />LORRY :Lynn '^ Everson
<br />r� SARAH BOHI ENKA1�tP
<br />2'0.2 5: 0.6 O C %• A DEPARTMENT OF HEALTHISTANT STATE R
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATEOR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, Nebraska
<br />7. SOCIALSECIIRIT1iNIJjN$ER
<br />506,824)840 .<
<br />5e. ROE - Last Birthday'
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not institution, give street and dumber)
<br />S@I$ct Specialty Hospital -Omaha (Central Campus)
<br />8c. CITY OR TOWN„OF'DEATH (Include Zlp Code)
<br />Ctimaha 8812
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />'9d. STREET A ND, NUMBER
<br />01 TUrtleSaei h
<br />9b. COUNTY
<br />Hamilton
<br />10a :reOrreI ETATUSAT TIME OF DEATH lia Married 0 Never Married
<br />g 0 Marled, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />•E.. 1.1. FATHER'&NAME; (First, Middle, Last, Suffix)
<br />k
<br />13 EVER:1N U.S 'Aft7/1 .#D'FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk) No
<br />w 15. METNOD OF DISPOSITION
<br />E>; ta:Crematiotl; Entombment
<br />014aiiovai.. ❑ fit• Si(Specify)
<br />1
<br />67::
<br />Mx UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Stt: PLACEco'DEATH
<br />HOSPITAL ;:.Igltripatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />sr.t
<br />23 05640
<br />3. DATE OF PE+ TH:;{Mo)
<br />April 2, 20
<br />6. DATE OF BIRm<.MD., •Day Yr
<br />February:.:24, 1056
<br />OTHER 0 Nursing Hoene/LTC
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />9c. CITY OR TOWN
<br />Marquette
<br />tie. APT. NO.
<br />9f. ZIP CODE
<br />68854
<br />lob. NAME OF SPOUSE (brat, :Y Middle, Last, Suffix) If wife, gnre maiden a ell
<br />Cindy Abernathy
<br />12, MOTHER'S NAME (First, Middle, Malden Surname
<br />CapitnIis :. ; Bussey
<br />14a. INFORMANT -NAME
<br />Cindy Everson
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Md. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Douglas Trade Service & Crematory
<br />7a. FUNERAL :HOME NAME AND MA LING AD RESS (Street, City or Torts), Stan)
<br />Solt -Wagner Funeral Home, 150717th Street, Central City::Nebra
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART t. Enter the chain of tents- dtauq, injuries, or compltcations that directly caused the death. DO NOT enter tannins! events such as cardiac arrest,
<br />respiratory arrest, or ventricular nbrtilation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 8 necessary.
<br />IMMEDIATE CAUSE:
<br />goggeivrg coking ' ';;: *Acute respiratory failure
<br />dit�(iee ermiesetoo melee
<br />Sequentially list condition•, if
<br />any, loading to the causs:listed
<br />EnturtM UNDERLYING CA17SE
<br />(disaaae:or lMury3kat tnlEMtnd
<br />the events moulting M death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Etiology undetermined
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />11k,IFART IL OTHER `SIGf i;)CANT CONDITIONS -Conditions contributing to the. death
<br />End stage renal disease, pleural effusion
<br />:.: ' {, .'N 1'tjI#gnintwldtln.pwitY1
<br />. . Prergieia atti1i1e fir dsaaf:::
<br />•trotPtignitrCinittrfitritint within 42 days of death
<br />m
<br />0 Nat pregnant, but pregnant43 days to 1 year before death
<br />;:.:> ❑ . Unknown E prs5npnt wit in the peat year
<br />at:'DATE:OP tNJURYiMo;Day, Yr.)
<br />22d.INJURY ATWORK?
<br />❑YES ❑ NO
<br />not intuiting .Mhe underlying cause given In •
<br />PART I.
<br />21a. MANNER OF DEATH .
<br />ElNatural q' Nonacid*
<br />0 Accident 0 Rending Invest
<br />0 Suicide ❑ Could nth b. determined
<br />22b. TIME OF INJURY
<br />•
<br />•
<br />21.b.,.IF TRANSPORTATION INJURY
<br />D 1Ver/Operetor
<br />la Feininger
<br />Psdeetd.n
<br />0 Other(specify)
<br />)Ice FOCI
<br />14b. RELATIONSttJP TO'bEGE1
<br />Spouse .
<br />16c. DATE (Mo., Drty,,YR)
<br />April 4, 2t 2;t€='>
<br />Nebraska '
<br />APPROXIMATE INTERVAL
<br />lg. WAS Opip :LEMI ...
<br />OR OORONER cONTA
<br />'OYU I NO
<br />21e. WAS AN AUTOPSY PERFgft l..
<br />❑ YES >:NIJ
<br />21d. WERE AUTOPSYFINCi**GSA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ vas Q.
<br />22c. PLACE OF INJURY: At barns,::farm, street, factory, office building, construction slfai
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2f LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 27. 2023 08:37 PM
<br />22d. Toll!. bastOf my knowtdge, death occurred at the time, date and place
<br />and du* to the cause(s) stated, (Signature and mI,)
<br />Darren J. Splonskowski, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES : El No '.:0 PROBABLY 0 UNKNOWN
<br />27k NAME; TITLE:ANDADORES& OF CERTIFIER (Type or Print
<br />Darren J . Splortsskowski, MD, 1870 S 75th Street, Omaha,
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENTGRANTED?:::..
<br />Not Applicable If 26a Is NO [J YES
<br />28b. DATE FILED BY REGIS
<br />April 27, 2023
<br />R (Mo., Day, Yr.)
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