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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 />7/13/2021
<br />LINCOLN, NEBRASKA
<br />202106320
<br />id, f 7 /3 It f1ks2.itt
<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 08664
<br />0
<br />at
<br />0
<br />1, DECEDENT'$ -NAME (First, Middle, Last, Suffix)
<br />Lola Mae Gartner
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 2, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Marysville, Kansas
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />506-38-6924
<br />8b'FACILITY-NAME<(if not Institution, give street and number)
<br />The Kensington
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />August 20, 1934
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED LIVING ...
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Hastings 68901 Adams
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Adams
<br />9c. CITY OR TOWN
<br />Hastings
<br />9d, STREET ANO NUMBER
<br />233 N. Hastings
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68901
<br />9g. INSIDE CITY LIMITS
<br />I YES ❑;'NO ".
<br />10a MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated E Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name°
<br />Elmer F Gartner
<br />11. FATHER°$:NAME (First, Middle, Last, Suffix) 1 12. MOTHER'S -NAME (First, Middle,
<br />Loyd R Marks
<br />Arta M Cromer
<br />Maiden Surname);
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Eugene D Gartner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />El Cremation ❑ Entombment
<br />❑ Remove) ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Jacob Nutz
<br />16b. LICENSE NO.
<br />1543
<br />16c. DATE (Mo., Day, Yr.)
<br />July 7, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Greenwood Cemetery Trumbull
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livirtt(stOri-Butter-Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska
<br />17b. Zip Code
<br />68901'.
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications.that directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pneumonia
<br />IMMEDIATE CAL/3E (Rina)
<br />disease Or condition resuIting
<br />M da$thf
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, :leading tothe mom :listed
<br />on a.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Weeks
<br />onset to death
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />onset to 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 underiying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?:
<br />0 YES E NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past: year
<br />0 1 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO:
<br />22a DATE
<br />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 />pacify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.;LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 2, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 2, 2021
<br />23c. TIME OF DEATH
<br />12:55 AM
<br />25d, TOths Wit of My knowledge, death occurred at the time, date and place
<br />acid duo Lathe cause(s) stand (Signature and Title)
<br />Paul Wibbels, MD
<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 o1 examination and/or investigation, in my opinion death pccurfed at
<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 E ND ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />E YES ❑ NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES E NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Paul Wibbels, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />July 6, 2021
<br />
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