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rhyatssF,;ko, 3 ;�;'et))_.____...STATE OF NEBRASKA
<br />al
<br />,t11l tMl1 :,;Vsiffeiyir'fy-,:: `;S�t\ItN1Hl%ii,
<br />�1u 11,t1,,d� �4�4d%s aeWil1, .�,wuil,.5,G1�!J11n„ 31 ,��i�i i;Gl/r
<br />pJJAdcca+:••:.<a¢YBfltlylifi�Ptr:La.r:': e:,Y,4hMxWJJdR.x>' is@xttbit�.t.191Ai3D�.;. vexrr.t�iMJJdssas,
<br />WHEN710- COP1':.CARRI THE RAISED SEAL OF STATE OF NEBRASI(A, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE:A T'RUE.CQFY;OP TO 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 />3
<br />DATE OF ISSUA7 t
<br />LINCOLN, NEBRASKA
<br />2026©0'59
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />E DENI .I- TAME; (Etirsk :. Middle, Last, Suffix)
<br />a nefa :;Je n :K.n:tiall
<br />TY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />grand <lsland:, :Nebraska
<br />SECURITY NUN aER
<br />50544-5410.;: > ''
<br />eb. FACILriY-NAME (If not lnstitution; give street and number)
<br />CHI Health St. Francis
<br />4e; GiTYsfR`#W1tF:birATFItnalude ZIP Code)
<br />Grand:Island ;688C :':"'
<br />w RESIDENCE -STATE'
<br />Nebraska
<br />94'llT4it 1`iliVp OWE '
<br />10s. MARlFAL STATUS AT'TiME OF D
<br />96. COUNTY
<br />Hall
<br />Married ❑ Never Married
<br />0 Married, but separated ❑wldewed ❑ Divorced ❑ Unknown
<br />11: r»ATHER'S,NAM : (First a:: Middle, Last, Suffix)
<br /><:JOseph::i erairi;, lu.
<br />EVER:IN LS, ARMED'.FORCE?
<br />(Yee, No, or Unlc) No
<br />15:•METsopioF DISPQS)TIQN
<br />Q DWfabeit:_;:,
<br />cremation ❑ Entgrf bll:Vel4t
<br />RsinoYsl ❑ carer (SPerary)
<br />CERTIFICATE Or QpATH.
<br />5e. AGE- Last alrthday
<br />(Yrs.)
<br />70..;
<br />56. UNDER 1 YEAR
<br />2, SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8s, PEACE O. DEATH
<br />HO8 ITA4. M Inpatient
<br />❑ ER/Outpatient
<br />DOA:' .:
<br />9c. CITY OR TOWN
<br />• ., Grand Island.
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing HoniILTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Oth APT. NO.
<br />91. ZIP CODE
<br />68803
<br />10b: NAME OF SPOUSE (First, Middle, Last, Suffix) Ifwife, give Mdden;moo
<br />Randall /Kendall
<br />:V
<br />14a. INFORMANT -NAME
<br />Randall Kendall
<br />Zia. FUNERAL DIRECTOR SIGNATURE
<br />Caleb J Alcorta
<br />1Z M0111ER'B LAME (First, Middle, Maiden Su
<br />Lucille •M> ...Fortin
<br />lob, LICENSE NO.
<br />1607
<br />111d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />p.;FUNERAt HOME NNIMEAND MA LING ADDRESS (Street, City or Town, State)
<br />Ail Faiths;Funeral Home, 2929 S. Locust Street, Grand Island,:. Nebraska
<br />148. RELADONSHI
<br />Spouse
<br />111c. DATE(Mo.,
<br />January 10,;•2.
<br />17b_ZII
<br />CAUSE OF DEATH (See )rl$tructions and examples)
<br />1. PART f, inter the chain ef Mr‘to. 41susres, injuries, or complicatMn,Hhat directly caused the death. 00 NOT enter tsnMnsl events such as cardiac Inset,
<br />respiratory anset, ormentrioulirtlbrllaMon without showing the *Solbgy. DO NOT ABRREVIATE. Enter only one cause on aIMe. Add additional tines if necessary.
<br />;:;:IMMEDIATE CAUSE.:
<br />err!ilaltiu+I�C4984(0hrt.; Cafdioresp)rlitoryfailure
<br />.. 4t0e0sa or;ca..aslf
<br />...I in death)
<br />::..
<br />sitlwndally Est conditions, tr
<br />erwi leading:le.the clueshated..
<br />the events nisuhing ha death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Septic Shock
<br />:AVE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR rS A CONSEQUENCE OF:
<br />4)
<br />u PART::.:11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death::but ttpt.reauttinq In the Underlying cause given In PART I.
<br />Enterococcus Bacteremla, Enterococcus Peritonitis, End Stage Renal Disease on Dialysis, Breast Cancer
<br />NatIK W nblk MAlhlnRt;
<br />.11,1 :,❑ Pd49nnitt;ri,iii ::cf,dss8i: `': 5::::
<br />i .,❑ Not pwghsnt, but pregnant. within 45 days of death
<br />❑ Not pregnant, but pregnant 4,1 days tot yes' before deth
<br />Unknorn) n:PraW*em wlth)n.M..e past year
<br />221 fU ttg QF;U'IJURY (M CO; Yr.)
<br />224. INJURY AT WORK?
<br />❑.Fd.::. ©:HO:: ..::
<br />21a. MANNER OF DEATH. <'
<br />® Natural ❑ Howls*
<br />❑ Accident 0 Pendinp:Investigotlon
<br />❑ Suicide 0 Could not be datemanad
<br />22b. TIME OF INJURY
<br />21p.IFTRANSPORTATION INJURY
<br />0 pdwrttharretor
<br />Paseengar
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />AI
<br />21d. yYERE AUT41F"
<br />TO COMPLETE CA
<br />© YES
<br />22c. PLACE OP INJURY -At Simi, street, factory, office building, constntgtlon
<br />au:De HOW INJURY OCCURRED
<br />4T1Ot(;OPiNJURYSTREET A NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo.; Dry, Yr.)
<br />December 23, 2625
<br />CITY/TOWN ... STATE
<br />2 b.,.ATSIGNEDHo. bay,Yr.) 23c
<br />. TiME OF DEATH
<br />7eni' 4 2020 Q512 Ply!
<br />tad. To sot, neat of)tiy hopplettos, death occurred at the time, date and piece
<br />imd di!it fn0 <000 stated. (Signature and MIN
<br />Venkata S Kanakadandi, MD
<br />24a. DATE SIGNED (M0., Day, Yr.)
<br />24b. TIME OP DEATH.
<br />24c PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME iP(PE
<br />On thii:04,1otpof examination and/or lmeetkiet p, in my
<br />the Pine; dite and place and due to the seua)s)staled.
<br />2ti.;:Ptp T01N CO USE COrv..iSUTE TO THE DEATH? 25a. HAS ORGAN OR TISSUE DONATION BEEN:GONSIDERED?
<br />YES NOS . ❑ PROBABLY ❑ UNKNOWN ❑ YES :' NO: ; .
<br />LI HAM T.E AII6i:AOpeale'OP CERTIFIER (Type or Print
<br />., VenkatlirS) a.ak;yitiandi, MD, 2620 W Fgidley Ave, brand Island' Nebraska/ 88803
<br />TRAR'B SIGNA'WRI
<br />25b. WAS CONSENT T BRA
<br />Not Applicable If 20s le NO
<br />25b. DATE FILED eV
<br />January?, 2026
<br />A
<br />Picllit :
<br />;y
<br />
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