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<br />ctt!C' STATE OF NEBRASKA
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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 />5/6/2020
<br />LINCOLN, NEBRASKA
<br />Amended
<br />202005804
<br />ca (a,, 7 r t .:P <rl. i2•rIt
<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 />20 05008
<br />Pursuant to sectic n 30-2473; demands for notice which May affect the estate of the deceased ars filed with the county covet in the county where the decedent resided at the time of death.
<br />1. DECEDENT$ -NAME (First, Middle, Last, Suffix)
<br />Dean R Kjar
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.);.
<br />April 19, 2020
<br />4. CITY AND STATEOR 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 />Lexington, Nebraska
<br />(Yrs.)
<br />62
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 29, 1957
<br />7, SOCIAL SECURITY,NUMBER
<br />507«88.9193
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC < ❑ Hospice Facility
<br />8b. FACILITY -NAME Ili not Institution, give street and number)
<br />Tabitha Nursing Home
<br />0 ER/Outpatient 0 Decedent's Home
<br />D DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68510
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9a.'RES1DENCESTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1404 Main Street
<br />30. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />YES 0 ND
<br />10a.:MARITAL 'STATIJSATTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Pamela Shellhammer
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Carl J Kiar
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Lea Gillen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 07/12/1976-08/14/1979
<br />14a. INFORMANT -NAME
<br />Pamela Kiar
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 21, 2(120
<br />Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Lincoln Cremation Service Lincoln Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Alternative Funeral & Cremation Services, 245 N. 27th Street, Suite B, Lincoln, Nebraska
<br />17b, Zip Code
<br />68503
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the chitin of events- 4beeses, injuries, or complications that directly caused the death. 00 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 it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE finer a) Multiple Sclerosis With Dysphagia And Aspiration
<br />disease or condition resulting
<br />onset to death
<br />PrOilreSsive<
<br />in aeadtl DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />Mt line a.
<br />' onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(dieoaae or injury that initiated
<br />on to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18.PARTII.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Aspiration Pneumonitis, Crohn's Disease, Primary Multifocal Leukoencephalopathy
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 Notpretanaat within past year
<br />Pregnant at rime of death
<br />0 Pre 9
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />❑ Not pregnant, bpi pr*gnant within 42 days of death❑
<br />0 Not pregnant, but pregnant 42 days to 1 year before death
<br />❑ Unknown if pregnant within the put year
<br />0 suicide 0 Could not be determined
<br />Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FIN DI NGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22*. DATE Off INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Spectfy)
<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 />To be:cOmpleted by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mgt 20, 2020
<br />23c. TIME OF DEATH
<br />01:30 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />ad, Ye the best of My knowledge, death occurred at the time, data and place
<br />du
<br />end **to the causes) stated. (Signature and Title)
<br />Mary Christensen, APRN-NP
<br />24e. On the basis of examination and/or investigation, in my opinion death =mitred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide),
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES $E NO >,❑ PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NOr
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Mary Christensen, APRN-NP, 4720 Randolph,
<br />Lincoln, Nebraska, 68510
<br />I28a. REGISTRAR'S SIGNATURES
<br />t
<br />Amended
<br />4/30/2020 Amended Item 13 No To Yes And Added Dates Of Service, Item 18, Part 1I Added Condition Primary Multifocal Leukoencephalopathy
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 20, 2020
<br />
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