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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 />6/30/2021
<br />LINCOLN, NEBRASKA
<br />202106427
<br />e ri7.ksi.
<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 />IPursuant 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. I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Sharon ! Lynn Kirby
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr)
<br />June 19, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />db. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />82
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 5, 1939
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-1518
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 88803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2116 West Faidiev Ave
<br />9e. APT. NO.
<br />323
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CI IMITS
<br />Ug YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Daniel Kirby
<br />name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Roy Schleichardt Marie Yates
<br />13.'EVER IN US. ARMED FORCES? Give dates of service N Yea.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Dana Kirby
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />'is. METHOD OF
<br />Q Burial
<br />DISPOSITION
<br />0 Donation
<br />0
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />June 22, 2021
<br />Cremation
<br />Q Removal
<br />Entombment
<br />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 UNG ADDRESS (Street, City or Town, State)
<br />All Faiths'Funeral<Home, 2929 S. Locust Street, 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 events- -diseases, injuries, or complications -hat 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 CAUSEIFaw a)RespiratoryFailure
<br />disease or condition resulting
<br />in dwtir)
<br />afloat to death
<br />2 Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Chronic Hypoxia
<br />any, leading to the cause listed
<br />on Ent A.
<br />onset to death
<br />10 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Recurrent Pneumonia
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />IS.4PART II. 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 />J YES ❑ NO
<br />20. IF FEMALE:
<br />0 **pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Q Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />Q Not pregnant, but pregnant within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />❑, Unknown It pregnant within the past year
<br />0 Suicide ❑could not be determinedQ
<br />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,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />AYES El NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION: OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B yi
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 19, 2021
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />IF ,
<br />E 1 4
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 21, 2021
<br />23e. TIME OF DEATH
<br />04:21 PM
<br />I i &
<br />I ` g
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />u 0
<br />E
<br />o :
<br />1
<br />23d. To the plat of my knowledge, death occurred at the time, date and place
<br />end dile 10 the causes) stated. (Signature and TRle)
<br />Douglas Herbek, MD
<br />$ Z
<br />e O u
<br />i.-§ S
<br />24e. On the basis of examination and/or Imre in my opinion death Occurred al
<br />sew time, date and place and due to the cacauses) stated. (Signature end Thiel
<br />cause(s)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Q YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO Q YES 0 NO'.
<br />27. NAME, 1i t.E AND ADDRESS OF CERTIFIER (Type or Print
<br />Douglas Herbek, MD, 2444 W. Faidley Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE�� 0 .s t
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 25, 2021
<br />
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