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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/5/2017
<br />LINCOLN NEBRASKA
<br />1. DECEDENTS (First, Middle, Last, Suffix)
<br />Alberta Marie Kent
<br />4. -CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rural Hall County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-30,8974.
<br />FAciulv (If not Institution, give street and number)
<br />Park Place-A Golden Living Center
<br />1:4
<br />0
<br />w Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />89
<br />513. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 25, 2017
<br />6. DATE OF BIRTH (MO., Day, Yr.)
<br />February 4, 1928
<br />8a. PLACE OF DEATH
<br />HOSPITAL J Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />OTHER E Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />< - 9a. RESIDENCE-STATE
<br />z w
<br />Netraska
<br />• 9d. STREET AND NUMBER
<br />624 Mavis Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married but separated 513 Widowed 0 Divorced 0 Unknown
<br />11. FA114ER'S-NAME (First, Middle, Last, Suffix)
<br />Albert Deichman
<br />1 EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes; No, or Link.)
<br />15. METHOD OF DISPOSMON
<br />El Burial Donation
<br />0 Cremation 0 Entombment
<br />0 Removal f1Othei9Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Smydra
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />Ilt 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 arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Coronary Artery Disease
<br />disease or condition resulting
<br />in death)
<br />•:': : „DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially gat conditions, if b)
<br />y lecu Ii. a ..0 ,114t13%.
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />,tliseasadelptuly thafinitiided
<br />the events resetting in death) DUE TO OR AS A CONSEQUENCE OF
<br />•• d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Atrial Fibrillation, Diabetes Type 2
<br />• ▪ 20. IF FEMALE: •••
<br />ri Not pregnant 'within past year
<br />LU • 0 Pregnant at time of death
<br />0
<br />Not pregnant, trot pregnant within 42 days of death
<br />'0
<br />Not pregnant;014 pmgnent 43 days to 1 year before death
<br />0
<br />unknown if pregitaritivithin the past year
<br />C d . 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />0
<br />224. iNJuRY.ATwoRk? 22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />t% Arartil 25, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH
<br />t.)
<br />April 25. 2017 11:15 AM
<br />0 3d. To the best of my knOwledge, death occurred at the time, date and place
<br />2 and due to the cause(s) stated. (Signature and Title)
<br />t iU
<br />Gary Settle, MD
<br />28a..REGIsTRARSsIONATLIRE
<br />. , . ..........„ . ..„.. .. . .. .
<br />201.800627
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH4AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />•
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Lewis Elmer Kent
<br />12. MOTHER'S-NAME (First,
<br />Edna Timpke
<br />14a. INFORMANT-NAME
<br />Gary Kent
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN
<br />Grand Island City Cemetery Grand Island
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />El Pedestrian
<br />Other (Specify)
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITY/TOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES E] NO
<br />26. DID' TOBACGOUSECONTRIBUTE TO THE DEATH?
<br />0 'YES El NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary: Sett*, 16W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />16b.. LICENSE NO.
<br />1454
<br />ate
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />9f, ZIP CODE
<br />68803
<br />STATE
<br />Suffix) If wife, give maiden name
<br />Middle, Maiden Surname)
<br />16c. DATE (Mo., Day, Yr.)
<br />May 1, 2017
<br />onset to death
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />9g. INSIDE CITY LIMITS
<br />I YES 0 NO
<br />onset
<br />onsett44eattf:::
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D YES E NO
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 Driver/Operator
<br />0 YES 50 NO
<br />0 Passenger
<br />ZIP CODE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<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 />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 yes 0 NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />STATE
<br />Nebraska
<br />68801
<br />APPROXIMATE INTERVAI-
<br />onset to death
<br />>10 Years
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />YES ONO
<br />CD
<br />I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.
<br />April 27, 2017 )
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