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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 />1/4/2021
<br />LINCOLN, NEBRASKA
<br />202103908
<br />)0 01 +d) +�FA4 .tYl.tt r1;_.L
<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 />2019005
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased ars filed with the county court in the county where: the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jimmie L Tuma <
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH 1Mo., Day,Yr.)
<br />December 28, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.) ;.
<br />Cotesfield, Nebraska
<br />(Yrs.)
<br />81
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 27, 1939
<br />7. SOCIAL SECURITY NUMBER
<br />507-52-0647
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Warbler Road
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />3925
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. 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 />3925 Warbler Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS;
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Mary Katherine Wheeler
<br />11. FATHER'S NAME (First, Middle, Last, Suffix)
<br />Clarence Tuma
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frances Klein
<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 />Mary Katherine Tuma
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑Burial ! ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 30, 2020
<br />lgi Cremation 0 Entombment
<br />❑Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All f=aiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events- 4iseases, injuries, or complications -that directly 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 a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Final a) Liver Failure
<br />disease or condition resulting
<br />onset to
<br />1 Year
<br />death
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Neuroendocrine Tumor, Metastatic
<br />any, leading to the cause listed
<br />onset to death
<br />6 Years
<br />online a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the U06RLYIN0 CAUSE C)
<br />(disease or injury that initiated
<br />onsett° death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART 11 OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER; CONTACTED?
<br />❑ YES lil NO
<br />0. IF FEMALE:
<br />❑:.Not pregnant within past year
<br />❑ Pregnantat time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑Homicide
<br />0 Accident IDPending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />`.❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES Ea NO
<br />Net pregnebt, butpregnawithin 42 days of death
<br />❑ nt
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑:Unknown if pregnant Within the past year
<br />❑ Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<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 site, ete. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />December 28, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 30, 2020
<br />23c. TIME OF DEATH
<br />04:56 AM
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />7d. To the best of my knowledge, death occurred at the time, date and place
<br />and due 10 the-cauwpj stated. (Signature and Title)
<br />Gary Settle, MD
<br />24.. On the basis of examination and/or investigation, in my opinion death occurred aY
<br />the time, date and place and due to the cause(s) stated. (Signature and Title);
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO '❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO OYES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE(____ 8.4
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 31, 2020
<br />
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