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<br />WHEN II 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 />7/21/2020
<br />LINCOLN, NEBRASKA
<br />202009108
<br />x �
<br />niof, 4.4'44
<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 09134
<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 />Richard A Koh!;
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 8, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b, UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />February 11, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />506-58-$424
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient OTHER ❑ Nursing Home/LTC Hospice Faoilicyl
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY
<br />Grand
<br />OR TOWN OF DEATH (Include Zip Code)
<br />Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />803 Sun Valley Drive
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />(t YES ❑ N(
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Hilde Muller
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Herman Kohl Jr
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Veda Mace
<br />13. EVER IN U.S. ARMEDFORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 1966-1969
<br />14a. INFORMANT -NAME
<br />Hilde Kohl
<br />14b. RELATIONSHIP TO DECEDENT:-.
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑'Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.)
<br />July 15, 2020
<br />Cremation ❑Entombment
<br />❑<Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston•Sonderinann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples) ,
<br />15. 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) Gastric Cancer
<br />disease oreondition resulting
<br />onsetto death
<br />6 Months
<br />in deethi DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />tine
<br />onset to death
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injure lthat initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />16, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the, underlying cause given In PART I.
<br />Septic Shock
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE;
<br />❑ Net pregnant within pat year
<br />❑. Pregnant : at time 44 death -'
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />, 0 Passeng
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />❑ Not pregnant, but pregnant within 42 days of deathSuicide
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ ❑ Could not ba determined
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22A. DA OFINJURY (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 />To becompleted by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 8, 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 />July 10 2020
<br />23c. TIME OF DEATH
<br />10:45 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the'.eause(s) stated. (Signature and Title)
<br />Gary Settle, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death oadurrad at
<br />the time, date and place and due to the cause(s) stated. (signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Q NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES:: 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settje, MO, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE3')
<br />Cz'zt.A 8a " "-tkiz---r'2f.--
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 15, 2020
<br />
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