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STATE OF NEBRASKA , F a ,,.,, .w T Zi t E 8 2 1 WHEN ! THIS !''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 10/18/2017 LINCOLN, NEBRA 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Harlan Grant Knoepfel 4, C ITY iAND STATEE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Farwell, Nebrask 7. SOCIAL SECURITY NUMBER 508 -30 -8123 FAC(LITY (If not Institution, give street and number) CH( Health St. Franntis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a, RESIDENCE STATE Nebraska 9d. STREET AND NUMBER 2132 Viking Place 10s. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated: s ❑ Widowed ❑ Divorced ❑ Unknown SKA 9b. COUNTY Hall 1. FATHER'S -NAME (First, Middle, Last, Suffix) Chris Knoepfel 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 08/25/1944- 07/04/1946 5. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal 0 Other (Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Ischemic Colitis disease or condition resuaing in death) Sequentially list conditions, if � .. . . b)Atherosclerosis any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE )disease or Injury tt[at initiated •the events reselling in death) LAST 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.:INJURY AT WORK? "..0 YES ONO 16a. EMBALMER-SIGNATURE Chris McCoy Westlawn Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Funeral Home, 1123 W. 2nd. Grand Island. Nebraska DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) t0. IF FEMALE: :; 0 Not pregnant within past year ❑ Pregnant at time of death Npt pregnant but pregnantwthin 42 days of death ❑Not pregnant, but pregnant:4a days to 1 year before death ❑ itiknown if pregnantwithtti the past year 22b. TIME OF INJURY 2e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. DATE OF DEATH (Mo., Day. Yr ! October 9, 2P1 23 DATE SIGNED (Mo.; Day, Yr.) ' 23c. TIME OF DEATH October 10, 2017 02:15 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Travis S. HaAeman, MD 28a. R GISTRAR'S SIGNATURE 201708516 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a, AGE - Last Birthday (Yrs.) CITY /TOWN 92 ++ 14a. INFORMANT -NAME Evelyn W Knoepfel 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined bi UNDER 1 YEAR M OS. Sc . CITY OR TOWN Grand Island U 2 5. DID T0#ACGO USE : NTRIBUTE TO THE DEATH? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 DAYS 9e. APT. NO. 2. SEX Male 1611. LICENSE NO. 1191 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island CAUSE OF DEATH ',See instructions and examples) PART I. Enter the Chain df events- - diseases, injuries, or complications -that directly caused the death.%) NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. STATE 24a. DATE SIGNED (Mo.. Day, Yr.) 240. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ig] NO MINS. 9f. ZIP CODE 68803 cor STANLEY S. "COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Martha M Lemburg 3. DATE OF DEATH (Mo., Day, Yr.) October 9, 2017 6. DATE OF BIRTH (Mo.,' Yr,) December 31, 1924 8a. PLACE OF DEATH HOSPITAL I Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 16b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name) Evelyn W Tagge Spouse 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver/Operator ❑ YES g] NO ❑ Passenger 0 Pedestrian 0 Other (specify) ❑YES ❑Nf) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 15. 4 4 u 9 ._ w z 24e. On the basis of examination and/or investigation, in my opinion death occurred at g 3 the time, date and place and due to the cause(s) stated. (Signature and Title) 28b. DATE FILED BY REGISTRAR (MO Day Yr.) October 11, 2017 October 12, 2017 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT 16c. DATE (Mo., Day, Yr.) STATE Nebraska 17b,Zip Code 68801 APPROX(MATEINT onset to de 2 Weeks onset to death ?' Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES RI NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 24d. TIME PRONOUNCED DEAD 28b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO RVAL ZIP CODE