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VDU <br />STATE OF NEBRASKA 2 <br />t�i{rllijl\1 <br />nratIfiN <br />tar) <br />WHEN ; THI5: : GOPY - CARRIES THE RAISED ' SEAL OF THE STATE OF NEBRASKA <br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL R <br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OFISSUANCE <br />7/7/2020 <br />COLN, NEBRASKA <br />DECEDENVS.NAME !First <br />.CDarrell Lee Penes <br />:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Nebrask <br />SOCIAL. sECuRITV N <br />506»T2-9153 <br />FACILITY!NAME,tIfit <br />6c. CITY OR.'rQWN.OF <br />a<S819B <br />Resioe L STATE <br />Nebraska <br />9d;'6TREET AND NUMBER <br />Si•143 N.'RruseAAve. <br />MARItAL STATUS AT <br />1..fATHER1S HAMS ( <br />Elmer Penes <br />e Zip Code) <br />I9b. COUNTY <br />Hall <br />2026001 6 Di SARAH'BHNNE KAMP <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 />6s. AGE • Lin <br />(Yrs.) <br />65 <br />2. SEX <br />Male , June , Tl <br />5C. UNDER 1 DAY S.DATE Op <br />5a. PLACE •OF-DEA!H . 1 <br />HOSPITAL ® Inp ivnt OTHER 0 Nursing Hume/LTC <br />• ❑ ER/Outpatient 0 Decedent's Home • <br />❑ DOA 0 Other <br />DIATt? OF DEA <br />UNTY OF DEA <br />Doug! <br />9c. CITY OR TOWN <br />Grand Island <br />De. APT, NO. <br />E OF DEATH 0 Married 0 Never Married 10b. NAME OF SPOUSE (Fired, MI <br />Widowed 0 Divorced 0 Unknown Pamela Kehm <br />EtiERIN U:S, ARMED FORCE <br />Nor or Urds.j YeS 0 <br />ETHOD OF DISPOSITION <br />ui(il 0•Donetiom <br />Crernitlon' ['Entombment <br />amours! :. Q0iher(Specih) <br />PARt1. Enka) <br />tuMEDlATE c <br />Maltase or:coedit <br />tr euti$.: <br />kMe, Lnt, Suffix) <br />Give diNs of service if Yes. 14s. INFORMANT•NAME <br />1973-12/23/1975 Pamela Penas <br />16 <br />BALMERSIGNATURE <br />3CCa S. Unger <br />6d, CEMETERY, CREMATORY OR OTHER LOCATION <br />Central Nebraska Cremation Services <br />OME,NAME AND M,AII.ING ADDRESS (Street, City or Town, State) . <br />l netaChapel,,3005 S. Locust St., Grand Island, Nebraska <br />Molly pet condiaona, If <br />y, !sapling to tin cants Ilated <br />n :i#kM R, <br />12, MOTHER'S -NAME (First. <br />Marian Skala <br />CAUSE OF DEATH (Seewjftstructi <br />, injuW*, or compacatlona4hat directly caused the death. 00 NOT caner terminal events such as cardiac arrut, <br />cuter fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N neonsmy. <br />IMMEDIATE CAUSE: <br />alAcute Hypoxic Respiratory Failure <br />116b. LICEN <br />1518 <br />Middle, <br />CITY / TOWN <br />Gibbon <br />, OR AS A CONSEQUENCE OF: <br />bl Se>?tic Shock <br />yjliii.ths UNDStiLYtNG C kli9E C <br />Mitith tititlrijiiiixxyythat7ntI $d <br />ire events reaueing fn'dnari n <br />!.AST <br />PART il. OTHF#t SI <br />yponatrernia, Dysphagia., <br />IF F <br />OR AS A CONSEQUENCE OF: <br />obattuctive Pneumonia <br />!B'TO OR AS A <br />Non -small C <br />00.preprM$ butphgrnrA*tthtn <br />© Not pregnant, but pregnant 43 days to 1 year before Ward <br />In the alai veer <br />SEQUENCE OF: <br />ung Cancer Of The Right Lung <br />CO N1 ITIONe$+Oondt <br />22a. DA <br />2 <br />o., <br />2 <br />y, Yr. <br />4. LOCATION OF INJIJRY'.STR <br />bey <br />an't due 1di tide ciuse(a$ iitated. (Si <br />nwvn'L Small, Mb <br />SC <br />AGCO USE.CONTRIBUT,E TO TH <br />0 N! <br />NAME,*UAW 'AbD <br />8raivyit'I�Smail: MD <br />EtiraISTRA <br />GNA <br />Y <br />buting to the death but not rssul€ing I <br />21s. MANNER OF DEATH <br />Natural 0 Homicide • <br />0 Accident 0 Pending Itrvatlastton <br />0 Suicide 0 Could not be determined <br />nd ex <br />m <br />nit effuse giv <br />21b. tF TRANSPORTATION INJVRYl21c. WA$A <br />Driver/Operator <br />Passenger <br />0 Pedestrian <br />0 Other (Specify) <br />OF INJURY 122c. PLACE OFINJURY tItome, term, sores <br />URY 0OCURRED <br />BER, APT.NO. <br />CERTIFI <br />910 N <br />da and place <br />aartdT lW) <br />TH? 26s. HAS ORGAN <br />KNOWN 0 YES <br />or Print <br />TION BEEN <br />of <br />and plan <br />STATE <br />and due <br />28b, DATE it` <br />July 1, 2po <br />20 08468 <br />TA E <br />A <br />o <br />