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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 />6/9/2020
<br />LINCOLN, NEBRASKA
<br />leceased are filed with the county court in tl
<br />202003991
<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 />. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Kenneth Wayne Alexander
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Memphis, Missouri
<br />7. SOCIAL SECURITY NUMBER
<br />493-28-6409
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY-NAME(If not Institution, give street and number)
<br />CHI Health St, Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island :68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1512 Church Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />90
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 07262
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Mav 28, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 2, 1929
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />®YES ❑ No
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donna Smith Olson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Bressler B Alexander
<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 />Donna Alexander
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Dono McDole
<br />14b. RELATIONSHIP TO DECE
<br />Wife
<br />DENT`
<br />15. METHOD OF DISPOSITION
<br />❑'Burial 0 Donation
<br />M, Cremation: ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />May 30, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />170. Zip Code
<br />68801
<br />estate of the
<br />to
<br />E
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. PART I. Enter the chain of events- dis , 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 (Finat a) Coronary Artery Disease
<br />disease or condition rutting
<br />In death)
<br />Sequentially list conditions, N
<br />any, leading to Ma cause fisted
<br />ontife a.
<br />Edtetthe UNDERLYINO:CAUSE
<br />...___O -__.. _.._.
<br />Wise-MgtOrinjuYy'that iiiitisted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART I1 OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />congestive heart failure, Aortic Stenosis, Diabetes. CKD
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />w
<br />c
<br />to
<br />E
<br />w
<br />' ty
<br />'tv
<br />10 a7
<br />. W
<br />LL
<br />a ick
<br />sx
<br />e ~ 2
<br />a
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Nregnantat5moor deem
<br />0 Not pregnant but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown It pregnent within Inc past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<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 />❑ YES EI NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES 0 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. (
<br />eciMY)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 28, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mav 29.2020
<br />23c. TIME OF DEATH
<br />02:07 PM
<br />3d. Tante beet of my. knowledge, death occurred at the time, date and place
<br />card -due [o the
<br />dause(s) stated. (Signature and Title)
<br />Travis S. Hammen, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis or examination andlor investigation, in my opinion death otturret8 at
<br />the time, date and place and due to the cause(s) stated. (Signature end Brie)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />27, NAME, TITLE AND ADbi`tESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES bi] NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ' ❑ YES
<br />CI NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 5, 2020
<br />1
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