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<br />WHEN ' THIS ' COPY CARRIES THE RAISED :SEALOF 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 />3/25/2020
<br />UNCOLN, NEBRASKA
<br />202002683
<br />j/2 -44,i) ekt/Ltaket.ht
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />20 02771
<br />1.peceDENrS..AME (First, Middle, Last, Suffix)
<br />John Francs Kemmerer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day
<br />February 29, 2020
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday
<br />64
<br />Philadelphia, Pennsylvania
<br />r. SOCIAL SECURITY NtJMBER
<br />159-46-5562
<br />e
<br />8
<br />c
<br />8
<br />�:. Xt : - iArsE't#f not Inedtu. ua, give sirear arid number.
<br />CHI Health St., Francis
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET ANDNUMBER
<br />104 Vine Street
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />84. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />LI ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Alda
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 7, 1955.
<br />OTHER 0 Nursing Home/LTC
<br />U Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />9g. INSIDE Gen, LIMITS
<br />® YES 0 NO
<br />10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Marled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />19b. NAME OF SPOUSE (First,' Middle, Last, Suffix) It wife, give maiden name
<br />Margaret Mary Zulkoski
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Horace Kemmerer
<br />12. MOTHER'S.NAME (First, Middle, Maiden Sumame)
<br />I
<br />Katherine O'Neill
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) Yes , 10/18/1979-07/19/1983
<br />14a. INFORMANT -NAME
<br />Margaret Mary Kemmerer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD QF DISPOSITION
<br />❑ Burial ❑ Donation
<br />Cremation ❑Entombment
<br />Removal ❑Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 4, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG 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 />18. PART I. Enter the chain of events diseases, injuries, or complications -that directly caused the death. DO NOT ender terminal events such as cardiac arrest,
<br />), ra. rut-ry witho•r..bm.4^^ •.e• aPr viaTc e„ry,,,tiva nn rxvna nn r tains. Ann adakMneh renes if nevem/my,
<br />', IMMEDIATE CAUSE:
<br />:e~� IMatEDIATE CAUSE (Final a) Bradycardia
<br />It, conditlOff recorder;
<br />q Sequentially llst conditions, N
<br />yd leading to tin cause listed
<br />on line a.
<br />Enter the UNDERLYINO CAUSE
<br />p (disease or Injury that Initiated
<br />E
<br />the events resulting in death)
<br />LAST
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />24 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Metabolic Acidosis
<br />onset to death
<br />48 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Septic Shock
<br />onset
<br />death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />16. PART SI.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not rssulting!In the underlying cause given In PART I.
<br />Atherosclerotic Vasorilar Disease, Acute Renal Failure, Coronary Artery Disease, Anemia Of Chronic Disease, Insulin
<br />Dependent Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease
<br />19. WAS MEDICAL` EXAMINER.
<br />OR CORONER CONTACTED?
<br />o YES NO
<br />. IF FEMALE:
<br />❑<Not meant volhin past year
<br />❑ Preceded at tine et death:
<br />❑ Not pregnant, Out pregnant within 42 aye of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the peat year
<br />220. DATE DFI YJURY(M0,. Day, Yr.)
<br />m
<br />•
<br />tt
<br />22d. INJURY AT WORK?
<br />❑ YES ❑NO
<br />221 LOCATION OF INJURY : STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 29, 2020
<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 />22c. PLAC
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />O YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES NO
<br />F INJURY -At home, farm; street, factory, office building; construction site, eta. (Specify)!
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 4, 2020 01:08 PM
<br />23d. TOR* beet army knowledge, death occurred at the time, date and place
<br />acid due to 1te:ceuse(s) stated. (Signature and Title)
<br />Manoi Survanaravanan, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES NO 0 PROBABLY El UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the heals of examination andfor investigation, In my opinion death occurred at
<br />9e time, dab and place and due to the cause(s) stated. (Signature and TWa)
<br />26a. HAS ORGAN OR TISSUE DONATION, BEEN CONSIDERED?
<br />❑YES LINO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO OYES 0 NQ
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 4, 2020
<br />
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