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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 />1/11/2021
<br />LINCOLN, NEBRASKA
<br />Amended
<br />202101190
<br />202102094
<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 18319
<br />at
<br />E
<br />o ❑YES .0 NO
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Larry Dean Emde
<br />4. CITY AND STATE OR; TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />O'Neill, Nebraska
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.; Day, Yr.)
<br />December 15, 2020
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />69
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., tidy, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />507-70-1375
<br />8b.'FACILITY.NAME (U not Institution, give street and number)
<br />616 W 6th Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />616 W 6th: Street
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />8& PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />September 20,:1951,;:.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />9g. INSIDE CrrY Lams
<br />ail yes ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Laura Brei
<br />11, FATHER S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />Melvin Geome Emde Lois Marie Bentley
<br />Maiden Surname)
<br />13. EVER IN U,S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Laura Emde
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Ea Burial 0 Donation
<br />Cremation 0 Entombment
<br />Removet ' 0 Other (Specify)
<br />16aa. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />December 18, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. zip Cods ::..
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- .ala , injuries, or complications -that directly caused the death. DO NOT anter terminal events such as cardiac arrest,
<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 />a/ Respiratory Failure
<br />IMMEDIATE CAUSE (final
<br />disease or condition resulting.
<br />in deem)
<br />Sequentially 11st conditions, if
<br />any, Wading to the cause listed
<br />on Eine a.
<br />Enter the ;UNDERLYINo-CRIME
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Dave
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) metastatic Lung Cancer
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onsette death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 I.
<br />Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Diabetes Mellitus 11,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?"
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ `Not pregnant Mthle Pest: year
<br />Pregnant at time* deatlS-
<br />❑.:Net pregnant, but pregnant within 42 days of death
<br />0Not pregnant, but pregnant 43 days to 1 year before death
<br />0
<br />Unknown a pregnant within the peat year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑`Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY :RNDINGSAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />2;;a, DATE OF INJURY (Me, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />' 22f :LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a 21 December 15, 2020
<br />2 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 18, 2020 02:08 AM
<br />tad. To the Asst of illy knowledge, death occurred at the time, data and place
<br />and drat hittM cause(s) stated. (Signature and Title)
<br />Katie L. Peters, APRN
<br />CITY/TOWN
<br />STATE
<br />IIP CODE
<br />0
<br />e ~i
<br />a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e.. On the basis of examination and/or investigation, in my opinion death occurred at
<br />)5 time, date and plata and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 VES'
<br />0 NO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Katie L, Peters, APRN, 2116 W Saidley Ave Ste 400, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />Q �i .tea �zx17k L f
<br />Amended
<br />1/11/2021 Items 8b, 9d 616 6th Street To 616 W 6th Street
<br />28b. DATE FILED BY REG)STRAR (Mo., Day, Yr.) I
<br />December 21, 2020
<br />
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