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STATE OF NEBRASKA ,
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<br />WHEN THIS 'COPY 'CARRIES' =THE RAISED SEAL OF THE STATE OF NEBRASKA, `4
<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, VITA,`
<br />RECORDS OFFICE, WHICH 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />GATE OF ISSUANCE
<br />1/19/2021
<br />LINCOLN, NEBRASKA
<br />2021.'0216 "4,7
<br />SARAH BOHNENKAMP.
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OE NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Pursuant to section 30-2413, demands for notice which may affect She estate of the deceased are filed with the county court In the county Where the decedent resided at the time of death.
<br />1. DECEDENV$.NAME (FBA - Middle, Last, Suffix)
<br />Ralph Lee Kaiser
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Me., Duy, Yy.)
<br />December 1L2020
<br />4. CITY: AND STATE QH TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE - Last Birthday
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr3
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />62
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 25,1958
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice FaCI$ty
<br />50846-4311.
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />824 10th Street
<br />0 ER/Outpatient ® Decedent's Home '
<br />0 DOA 0 Other (Specify)
<br />West
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) -
<br />Grand Island 68801
<br />.
<br />I Bd. 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 />824 West 10th Street
<br />as. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />'9p. INSIDE CITY1.UMITS
<br />121 YES ' ❑ NO.!
<br />10a, MARITAL STATUS AT 11ME OF DEATH ❑ Married 0 Never Married
<br />❑ Married, but separated 0 Widowed ® Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nano
<br />11. FATHER'S -NAME trivet, Middle, Lest, Suffix)
<br />Ronald Wayne Kaiser
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) '
<br />Ruth Schoenstein
<br />13. EVER IN U.$, ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Brenda Kaiser
<br />14b. RELATIONSHIP TO DECEDENT
<br />Ex -Wife
<br />15. METHOD OF DISPOSITION
<br />Q Burl$ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 1E 2021
<br />r0
<br />it Cremation 'U Entore6ment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />._ -
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral. Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />17b. Zip Code
<br />68801'::
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events,. diseases, Injuries, or complIatlona4hat dlrectty caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without shoving the etiology. DO NOT ABBREVIATE. Enter only one cause on • ane. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pinal a) Pancreatic Cancer
<br />dtsease or condition restriking '.
<br />'
<br />onset to death
<br />Montell
<br />in death; DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially lid conditions, if b)
<br />any, leading to the case Meted
<br />onset to death
<br />on 11M L
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eder** UNDERLYING CAUSE c)
<br />(disease or Injury that Initiates
<br />On{etlf7death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />!AST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Diabetes Mellitus Type 2, Hypertension
<br />19. WAS MEDICAL ExAMINER
<br />OR CORONee<CONTACTIED?
<br />❑ YES ®NO
<br />20r.- �ItF FEMALE:_
<br />LJ. Not pregnentwiddnpast year
<br />Wath
<br />21a. MANNER OF DEATH
<br />® Natural ❑'Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Pessenger
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Vii:. NO
<br />❑ Preened te time or
<br />0 Not dunned, but pregnant within 42 days of dem❑
<br />❑ Not pregnant, but pregnant 43 days 40 1 year before death
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide El not be determined
<br />Pedeatnan
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />❑ Unknown If pregnant within the peat year
<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 sits, *C. (Specjfyi
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />224. LOCATION OF INJURY''- STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP ODS
<br />B$
<br />23a. DATE OF DEATH (Mo., Day, Yr.)_
<br />December 18, 2020
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />S Y
<br />z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />18. 2020
<br />23c. TIME OF DEATH
<br />06:12 AM
<br />1 IP
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />1I
<br />:December
<br />3d. Ts the beat Omit knowledge, death occurred
<br />and due*** brume( s) stated. (Signature and
<br />Chad Vieth, MD
<br />at the time, ate and place
<br />Title) .
<br />1 Ei
<br />' a
<br />r 8
<br />toe. On the basis or examination and/or Investigation, In my opinlon deem 05531040 411
<br />the time, ate and place and due to the eause(e) stated. (SIgMtureind)!Ide) •:: ,
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 1J PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />28b. WAS CONSENT GRANTED?.
<br />Not Applicable If 26a Is NO 0 YES ❑ N0
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MO, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />SIGNATURE--)
<br />28a. REGISTRAR'S SIGNATURE28b.
<br />8i>11lt-.s?ket.4- c
<br />DATE FILED BY REGISTRAR (Mo., Day,Yr.)
<br />January 13, 2021
<br />
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