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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF 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 />1
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<br />Sl:
<br />DATE OF tssUANCE
<br />10/28/2025
<br />LINCOLN, NEBRASKA
<br />2026058 `1 7 SA(RH H+� M iyt.
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />DECEDENTIPNAME (First, Middle, Last, Suffix)
<br />Irene Eleanor Avery
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-66-1984
<br />6a. AGE • Last Birthday
<br />(Yrs.)
<br />93
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />tic. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2514136
<br />3. DATE OF DEATH (MO., Day Vt i
<br />October 13, 2025
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />FACIUTY-NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />SC. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />w . Nebraska
<br />Id. STREET AND NUMBER
<br />3119 West Feld* Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Christian Peterson
<br />13. EVER IN U.B. ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />is, METHOD OF DISPOSITION
<br />Burlal ❑ Donation
<br />❑ Cremation Q Entombment
<br />❑ Removal 0 Other (Specify)
<br />Oa. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />November 5,::1931
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ke: APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0. Hospice Fseitb
<br />09 INSIDE CITY LEMITS'
<br />51 YES LI 1uo <,:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Laura Nelson
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Brandon S Bachle
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Zelma Nelson
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />1T0. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aptel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />lib. LICENSE NO.
<br />1537
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examoiesl
<br />18. PART I. Enter the chain of events- -diseases, Injuries, or complications that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory sweet, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one came one sine. Add additional lines E necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE cams (Pines -a) Respiratory Failure
<br />disease at condition resulting:
<br />In death)
<br />Sequentially list condition!, If
<br />any, leading to the: cause Iietea
<br />an liars>a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Whined
<br />tha events resulting In death)
<br />LAST
<br />1a. PART II: OTN
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter ..
<br />16e. DATE (Mo:,Day,Yr.),
<br />October 18, 2025
<br />STATE
<br />Nebraska
<br />1T1i Zip Co4F
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset tor/SOH
<br />Two Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Bacterial Pneumonia
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />c) Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />R'SIGNfFICANT CONDITIONS -Conditions contributing to the death but not raaulti:0 lathe underlying cause given in PART I.
<br />20. IF FEMALE:
<br />❑ Npt pregnant within past year:.
<br />❑ Pregnant at SOW of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown 0 pregnantMthIn the past year
<br />220. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.1F TRANSPORTATION
<br />_Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑_Other (Specify)
<br />INJURY
<br />onset to death
<br />Two Weeks
<br />onset to OH*
<br />Years
<br />19. WAS MEDICAL' EXAMINER'
<br />OR CORONER CONTACTED?
<br />❑ YES NO.
<br />21c. WAS AN AUTOPSY PERFOI. NED? •
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?.
<br />❑ Yes ❑ rib
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction elb, eto.:{> tic$fy)
<br />22d. INJURY AT WORK?
<br />❑;YES ❑NO;
<br />22*. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION 05 INJURY .STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE CODE
<br />2
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 13, 2025
<br />tab. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 22. 2025 05:22 A )
<br />=ask To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Douglas Herbek, MD
<br />26 DI¢ TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES FINO CI PROBABLY 0 UNKNOWN
<br />2?. NAME, TITL ND ADDRESS OF CERTIFIER (Type or Print
<br />Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />211s. REGISTRAR'S SIGNATURE
<br />6k -24_1i 8 L 11k4 z f
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24gs
<br />24b. TIME 0I1 DEATH
<br />PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED
<br />DEAD
<br />20.On OWNS* or examination enwor Inwa8gstion, in my opinion dank oeaun�ed M
<br />the time, date and place and due to the cause(a) Muted. (Signsture sad Ties)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN: CONSIDERED?
<br />❑YES 14NO
<br />4tsb. WAS CONSENT GRANTED?!'
<br />Not Applicable if 264 le NO DYES
<br />El t,10
<br />26b. DATE FILED BY REGISTRAR (Mo Day, Yr}
<br />October 22, 2025
<br />
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