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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 />6/17/2021
<br />LINCOLN, NEBRASKA
<br />202105779
<br />81 -It 004-44 t*
<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 />21 07854
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are 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 />Robert Allen Krell
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 12, 2021
<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 />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Oklahoma City, Oklahoma
<br />(Yrs.)
<br />82
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />April 2, 1.939
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-4146
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Brookefield Park
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c, CITY OR TOWN OF DEATH (include Zip Code)
<br />St. Paul 68873
<br />8d. COUNTY OF DEATH
<br />I Howard
<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 />1322 Howard Place
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INStDE CITY UM)TS<
<br />® YES 0 No
<br />boa. 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 />Pam Chapman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert A Krall
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bessie Shattuck
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/24/1961-03/21/1962
<br />14a. INFORMANT -NAME
<br />Pam Krell
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />I Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />16b. LICENSE NO.
<br />1448
<br />16c. DATE (Mc., Dsy, Yr.)
<br />June 19 2021
<br />13 CrematIon ❑Entombment
<br />❑ Removal ` 0 Other (Specify)
<br />16d.CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801!
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART I. Enter the chain of ewes- -diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Respiratory Failure
<br />disease or Condition resulting`
<br />onset to death
<br />Days
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Congestive Heart Failure
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />Months
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERCYINGCAUSE C) Cardiomyopathy -
<br />(disuse or Injury that initiated
<br />onset to death
<br />Years
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Hypertension
<br />Onset to death
<br />Years
<br />18. PART Ii. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Lymphederna, Chronic Renal Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF
<br />0
<br />0
<br />FEMALE:
<br />Not pregnant within past year
<br />Pregnant at time of deeth'
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />i: Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />❑
<br />o
<br />❑:
<br />Not pregnant, but pregnant within 42 days of deathSulcida
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />Could notdetermined
<br />0 ❑ be
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />2214. 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, etc.
<br />(Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES, ❑ N0_
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />S tj
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 12, 2021
<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 />F
<br />I cl c
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 14, 2021
<br />23e. TIME OF DEATH
<br />05:58 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />2 qy
<br />o w,.
<br />a
<br />yd. Tothe bestof my knowledge, death occurred at the time, date and place
<br />anti due tstM eauesp) stated. (Signature and Title)
<br />Jared Kramer, MD
<br />24a. On the. basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and due to the causerie) stated. (Signature and Title) ..
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Ea NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Ea NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO `' ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jared Kramer, MD, 1113 Sherman St, St. Paul,
<br />Nebraska, 68873
<br />28a. REGISTRAR'S SIGNATUREa� 8
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)4.}7
<br />June 16, 2021
<br />
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