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m0050.1 +p�S��"'4"�� r4RWdNdw ..... vkFSdOtyt�.lerP088e r e kr5ei4q'Aih ?€trd694tftdAS:�.:..,.y c irrrrhmt 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 1/4/2021 LINCOLN, NEBRASKA 0 2 a a E 202102413 ,11 tUtikel SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME '(First, Middle, Last, Suffix) Larry Gene Klein 4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pleasanton, Nebraska 5a. AGE - Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 20 18837 3. DATE OF DEATH (Mo., Day, Yr.) December 21 2020 6. DATE OF BIRTH(Mo., Day, Yr.) December 8, 1934. 7. SOCIAL SECURITY NUMBER 508-40-1742 Bb.FACILITY-NAME (If not Institution, give street end number) CHI Health St. Elizabeth 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68510 9a. RESIDENCE -STATE Nebraska 9d, STREET AND NUMBER 2305 Gateway Ave! 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Lancaster 9e. APT. NO. 9f. ZIP CODE 68803 ❑ Hospice Facility 9g. INSIDE CITY LIMITS 0 YES ❑ NO 101). NAME OF SPOUSE ;Firm, Middle, Last, Suffix) If wife, give maiden name. Rocene Johns 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thomas Klein 12. MOTHER'S -NAME (First, Middle, Helen Krietzer Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rociene Klein 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial ❑ Donation Cremation 0 Entombment Removal i' 0 Other (Specify) 18a. EMBALMER -SIGNATURE Not Embalmed 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 25, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE 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) 1e. PART I. Enter the chain of events- di , Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 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 CAUSER OIa)Acute Renal Failure disease or dondition resulting,'(. In depth) Sequentially list conditions, if any, leading to the cause listed online a Enter the UNDERLYING CAUSE (dis`rm& or Injury that Initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b)Congestive Heart Failure APPROXIMATE INTERVAL onset to death Days onset to death Years DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. :PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Pneumonla 19. WAS MEDIOAL EXAMINER OR CORONER CONTACTED?' ❑ YES ®NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time 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 E Natural ❑ Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 DnverlOperator ❑ Pateenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO. 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? O YES 0 NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spectry) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION: OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN r�+ a } 23b. DATE SIGNED (Mo., Day, Yr.) 2 0 December 22, 2020 fid. Toth. twat of my knowledge, death occurred at the time, date and place e.,0. ani( am to the causal') stated. (Signature and Title) ' f Krista Goins, MD a• , 23a. DATE OF DEATH (Mo., Day, Yr.) December 21 2020 23c. TIME OF DEATH 01:10 PM 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY 0 UNKNOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e, On the basis of examination andior investigation, in my opinion death occurred did the time, date and place and due to the causes) stated. (Signature end Tiffs) e: 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable If 28a Is NO 0 YES: ❑N0 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Krista Goins, MD, 555 South 70th St, Lincoln, Nebraska, 68510 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 29, 2020 0 CO CO