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; S? I:4,4, iimpeif iva.,,.4t011, 11/Gyl0I31rw.rtl8onr4igi'Ailv. ititIl Stitt llil'(sNii;;;;,ai(iMiA4 sE rt er r er ■r,.er sa-s irirli)(E14gt+ ea aEr4tttyArrflftSt, EBrt,PN,wS : rEq�t7tABrrlNSv 3 rrrrrm 4110 myorfor illsooto outtduao 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 1/11/2021 LINCOLN, NEBRASKA Amended 202101190 y [ '.341.4SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Larry Dean Emde 4. CITY AND STATE OR; TERRITORY, OR FOREIGN COUNTRY OF BIRTH O'Neill, Nebraska 7. SOCIAL SECURITY NUMBER 507-70-1375 5a. AGE • Last Birthday (Yrs.) 8b.'FACILITY•NAME (If not Institution, give street and number) 616 W 6th Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 69 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island HOURS MINS. rhe YhYdll�aa,�a:41)41 3. DATE OF DEATH December 15 2018319 Mo., Day, Yr.) 2020 6. DATE OF BIRTH (Mo., Days Yr4 September 20, 1951 OTHER 0 Nursing Home/LTC E Decedent's Home 0 Other (Specify) I8d. COUNTY OF DEATH Hall Hospice Fad(lity 9d, STREET AND NUMBER 616 W 6th' Street 8e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CIIYLIMITS'. 64 yes ❑ NO 104, MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (first, Middle, Last, Suffix) If wife, give maiden name' Laura Brei 11. FATHER S -NAME (First, Middle, Last, Suffix) Melvin George Emde 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lois Marie Bentley 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Laura Emde 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION RI Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) December 18, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska 17e. FUNERAL HOME NAME AND MA UNG 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 I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or veMncular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: a)Respiratory Failure IMMEDIATE CAMtSE (Heal 'Oases, or conditbn resuaaall_ in death) Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that Initiated the events resulting In death) LAST APPROXIMATE INTERVAL onset to death Days DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Lung Cancer onset to death Months DUE TO, OR AS A CONSEQUENCE OF: c) onset t° death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I. Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Diabetes MellituB 11, 20. IF FEMALE, ❑ Nat Pregnant within past year Preonant at ume of death.' 0 Not pregnant, but pregnant 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 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 21a. MANNER OF DEATH Natural ❑ Homicide 0 Accident 0 Pending Invaetigelon 0 Suicide 0 Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator `❑ Passenger ❑'Pedestrian ❑ Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?' ❑ YES ,.,E NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 151,1 NO 21d. WERE AUTOPSY FiNDINGSAVAIL/FBLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sfe etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 6 a 8 �x 23a. DATE OF DEATH (Mo., Day, Yr.) December 15, 2020 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) DIcember 18, 2020 add. TO the befit 0 My knowledge, death occurred at the time, date and place find dip to ilia eause(s) stated. (Signature and Title) Katie L. Peters, APRN 23c. TIME OF DEATH 02:08 AM 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO '❑ PROBABLY E UNKNOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP -CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or Investige Ion, In my opinion daathacturrad at the thne, date and place and due to the cause(s) stated. (Signetur4And'ntla) :' 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES' ❑NO¢ 27 NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Katie L, Peters, APRN, 2116 W Saidley Ave Ste 400, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 21, 2020 Amended 1/11/2021 Items 8b, 9d 616 6th Street To 616 W 6th Street 1 Q Cb Ca