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.'@Pf wurttyg 'f>r..^, wsparajraupVP :.. WHEN THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 6/2/2020 LINCOLN, NEBRASKA 202005928 SARAH BOHNENKAMP 1 ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 06828 Pursuant to section 30.2413, demands for notice which may affect the estate of the deceased ant filed with the county court In the county where the decedent resided at the time of death. I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Nancy Sue Knapp 2. SEX Female 3. DATE OF DEATH (Mo.,. Day, Yr.) Mav 24, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, W.) Aurora, Nebraska (Yrs.) 67 MOS. DAYS HOURS MINS. December31, 1952 7. SOCIAL SECURITY NUMBER 50770.0866 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY.NAME (If not Institution, give street and number) 1810 Park Avenue 0 ER/Outpatient El Decedent's Home ❑ DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1810 Park Avenue Be. APT. NO. 9f. ZIP CODE 68803 90. INSIDE CITY LIMITS M YES Q NO 10e. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name John Wayne Knapp 11. FATHER'S.NAME (First, Middle, Last, Suffix) Raymond Ortearen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Melba Ann Wilshusen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 14a. INFORMANT -NAME John Wayne Knapp 14b. RELATIONSHIP TO DECEDENT ". Spouse 15. METHOD OF DISPOSITION ❑ Burial []Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) May 27, 2020 iii Cremation ❑Entombment 0 Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral' Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events- -d , injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (KW a) Metastatic Colon Cancer disease or condition resulting onset to death Months in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If b) any, leading to the cause listed onset to death online 8. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease*, injury that initiated onset death me events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART If. DINER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Nicotine Dependence 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: El Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH El Natural 0 Homicide ❑Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO 0 ,Not pregnant, but *Want within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown If pregnant within the past year guicide Could not be determined 0 ❑ 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Moi, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATIQN OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a 23a. DATE OF DEATH (Mo., Day, Yr.) May 24, 2020 To be completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 3 I o z 23b. DATE SIGNED (Mo., Day, Yr.) May 27, 2020 23c. TIME OF DEATH 09:55 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 U., 230. To the twat of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Zachary W. Meyer, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred* the time, date and place and due to the onuses) stated. (Signature and Ttda) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 21 YES 0 NO i❑ PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES El NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ' 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE Z) L avZ .8d 11.... f? �tLrvL/ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I May 28, 2020 rn 0 Cn CA)