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<br />STATE OF NEBRASKA
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<br />WHEN THIS I'` 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 />.41120180764 1 RUSSELL F SLER REGI
<br />SSI5TANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />11/16/2018
<br />LINCOLN, NEBRASKA
<br />CERTIFICATEOF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Rodney Merritt Hammond
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 5, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Wheatland, Wyoming
<br />(Yrs.)
<br />73
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />July 18, 1945
<br />7. SOCIAL SECURITY NUMBER
<br />505-58-4625
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER E Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME Pinot Institution, give street and number)
<br />Park Place -A Golden Living Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />Cc. CITY OR TOWN OF DEAL ....-!u SZip'Code) ird. COUNTY or DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />_
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />320 Arapahoe Ave
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />E YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated E Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Barbara Osentowski
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />LeRoy Hammond
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marie Robbing
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />14a. INFORMANT -NAME,
<br />Brigitte Dickey
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Grant Chapin
<br />16b. LICENSE N0.
<br />1172
<br />16c. DATE (Mo., Day, Yr.)
<br />November 9, 2018
<br />E Cremation 0 Entombment
<br />❑ Removal ; 0 Other: (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Mt. Hope Cemetery Sargent Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Govier Brothers Mortuary, Inc.. 542 South 9th, PO Box 665. Broken Bow. Nebraska
<br />17b. Zip Code
<br />68822
<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 as cardiac arrest,
<br />APPROXIMATE INTERVAL.
<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) End Stage Renal Disease
<br />disease or condition resulting
<br />in death)
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially hst conditions, if b) Diabetes Type II
<br />any, leading to the cause listed
<br />on line a.
<br />onset to death<
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Hypertension
<br />(disease or injury that initiated¢
<br />onset to dcatt.
<br />Years
<br />the events resulting ,n death) DUE T0, OR AS A CONSEQUENCE OF:
<br />LAST ,. dj
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but
<br />not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO<
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of deathassen
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />g
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES E NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 03 days to 1 year before death
<br />0 Unknown 4 pregnant within the past year
<br />0 suicide 0 CouId not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />)mpleted by
<br />CERTIFIER:..
<br />INLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 5 2018
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 8, 2018
<br />23c. TIME OF DEATH
<br />01:57 PM
<br />= = K
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />rau. .
<br />a :,e ,. -_ vya._za.� _..�„c� -. .-._ -.. - . � ....
<br />oand due to the cause(s) stated. (Signature and Title)
<br />0
<br />2 Michael A.Donner, MD
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<br />o e
<br />_
<br />..,_, a .... .a^y.� Ceafl! ccrur.ed .t
<br />thehtime, date and place and due to the cause(s) stated. (Signature and 1rtle)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 15, 2018
<br />
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