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DATE OF ISSUANCE
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA, MENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,R,EC;ORDS. e
<br />01/16/2015
<br />LINCOLN, NEB
<br />2015023
<br />NL
<br />5 $TA'EY S CQOPER ', r ,
<br />A$$ISTANT STATE REGISTPA,R ,
<br />DEPARTMENT,OFAIE.ILTH AND NEBRASKA H(,IMANSERtfiCCSL , .�' •
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES: ^
<br />CERTIFICATE OF DEATH . ,
<br />15 00151
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Kenneth Willilam Kroeger
<br />2. SE/( '
<br />Mal t . ` ' :.
<br />3. DATE OR DEATH (Mo., Day, Yr.)
<br />t' January 9, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Merrick County, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1'DAY, '
<br />, & DATE OF BIRTH (Mo., Day, Yr.)
<br />October 16, 1932
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508 -32 -3523
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Veterans Home
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />r
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1628 Virginia Drive
<br />9e. APT. NO.
<br />1
<br />9f. ZIP CODE
<br />I 68803
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Erma Jean Lorenzen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William F Kroeger
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lillian M Luebbe
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or una.) Yes 01/08/1953 - 12/09/1954
<br />14a. INFORMANT -NAME
<br />Erma Jean Kroeger
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />16c. DATE (Mo., Day, Yr.)
<br />January 13, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such se cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Coronary Artery Disease.
<br />disease or condition resulting
<br />onset to death
<br />> 1 Year
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b) I
<br />any, leading to the cause listed I
<br />1
<br />online a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE c) I
<br />(disease or Injury that initiated 1
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) 1
<br />I
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Parkinsons Disease; Diabetes Mellitus, Type 2; COPD; Vascular Dementia.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />2, w
<br />$ F
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 9, 2015
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<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 12, 2015
<br />23c. TIME OF DEATH
<br />I 09:45 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />� t O 3d. To the bast of my knowledge, death occurred at the time, date and place
<br />B c and due to the cause(s) stated. (Signature and Title)
<br />A. Gene L. Wyse, DO
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gene L. Wyse, DO, 2300 West Capital Avenue
<br />Grand Island, Nebraska, 68803
<br />128a. REGISTRAR'S SIGNATURE jej
<br />� Y V
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 13, 2015
<br />DATE OF ISSUANCE
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA, MENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,R,EC;ORDS. e
<br />01/16/2015
<br />LINCOLN, NEB
<br />2015023
<br />NL
<br />5 $TA'EY S CQOPER ', r ,
<br />A$$ISTANT STATE REGISTPA,R ,
<br />DEPARTMENT,OFAIE.ILTH AND NEBRASKA H(,IMANSERtfiCCSL , .�' •
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES: ^
<br />CERTIFICATE OF DEATH . ,
<br />15 00151
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