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<br />STATE OF NEBRASKA
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<br />WHEN 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 />3/5/2020 �ataC.� a .t •Inlet•
<br />LINCOLN, NEBRASKA 202102709 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 />0
<br />1. DECEDENTS -NAME (Flat, Middle, Last, Suffix)
<br />Ronnie Ray SItzman
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />McCook, Nebraska
<br />5a, AGE - LastSIrthday
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />lrlrl 0Phi4'i'/4c))1�1ri lr((jlr,',',14
<br />��1��1��1aa 11r�1t•>�1�)h4%ri1 ;�i(ii�iifPO,rt/u
<br />20 02611
<br />1. DATE OF DEATH (Mo., Day,Yt.
<br />February 19, 2020
<br />6. DATE OF BIRTH {Mo., Day, Yt.)
<br />7. SOCIAL SECURITY NUMBER
<br />505-90.7792
<br />8b. FACILITY -NAME (iffOt Institution, give street and number)
<br />US 1-80 mm296 East Bound
<br />5c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />11 Shelton 68876
<br />la 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3936. Hampton Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />ID
<br />o 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />to 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />3 Gerald Sitzman
<br />,. 13. EVER IN U.S ARMED FORCES? Give dates of service B Yes.
<br />8 (Yes, No, or Link.) No
<br />8
<br />15. METHOD OF DISPOSITION
<br />®audal ❑Donation
<br />❑ Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />January 27., 1961
<br />OTHER 0 Nursing Home/LTC
<br />D Decedent's Home
<br />Other (Specify)Road Side
<br />18d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />ptce FsCJiIty .
<br />9y INSIDE GITY.( M178
<br />Q i Eti ❑ No
<br />lab NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />Darla Hapemann
<br />14a. INFORMANT -NAME
<br />Darla Sitzman
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Betty Schnieder
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />16b. LICENSE NO.
<br />1448
<br />16c. DATE (Mo., Day, Yr.)
<br />February 29. 2020
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Culbertson Cemetery
<br />CITY / TOWN STATE
<br />Culbertson Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />ARfel Funeral Horne. 1123 W. 2nd, Grand Island, Nebraska
<br />170. ZIp Code
<br />68801:
<br />1
<br />d
<br />CAUSE OF DEATH (See Instruct ns and examples)
<br />11. PART I. Enter the chain of events -.diseases, Injuria, or compllatlona4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cases on a line. Add addhioal Imes if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAWS final a)Unknown Natural Causes
<br />MUM* arsonISion relukin9
<br />in dainty) _....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, leading to 114* cause gated
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enteritis UNDERLYING CAUSE c)
<br />'( (disease er injury that initiated
<br />S tM events n'uRlng In oath) DUE TO, OR AS A CONSEQUENCE OF:
<br />a LAST
<br />d)
<br />ID
<br />ft 18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the depth but not resulting In the underlying cause given In PART I.
<br />Reported History Of Heart Concerns
<br />a .20. IF FEMALE:
<br />E ❑ Not pggnaM within Rooter
<br />0 Pregnant Aniline of dath
<br />❑ fist pregners, but pregnant within 12 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown 8 pragnam within the past year
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />APPROXIMATE INTERVAL
<br />onset:to death
<br />Immediate
<br />onset to death
<br />onset
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident :IPending
<br />Imatipaton
<br />0 Suicide
<br />0 Couldnot b. dsarmlaA
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />OYES ❑NO..:.
<br />22f. LOCATION OF INJURY>: STREET & NUMBER, APT.NO.
<br />21b. IF TRANSPORTATION INJURY
<br />DrivprlOperator
<br />❑ Pa*Mnger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑. NO ..
<br />22c. PLACE OF INJURY -At horns, farm, street, factory, office building, construction site, etc (Specify);'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEA
<br />134. UM* best of myknowledge, death occurred at the time, data and p
<br />OM Me to pia cau's(*) stead. (Signature and Me)
<br />Tt
<br />e
<br />V
<br />u
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 2, 2020
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 19. 2020
<br />24b. TIME OF DEATH
<br />Approx. 04:43 PM
<br />24d. TIME PRONOUNCED DEAD
<br />_ 05:30 PM`'
<br />Toe. On the basis of examination and/or investigation, In my op4dan deadt .starred
<br />t b dna; date and pace and due to the causal.) stated. (Signature end Tale)
<br />Sarah Carstensen, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE
<br />DONATION BEEN CONSIDERED?
<br />❑ YES 131 NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY IKI UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 3, 2020
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