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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 />8/18/2021
<br />LINCOLN, NEBRASKA
<br />e ©
<br />2 0 210 1ry6 2 8 ASSISTANT STATE REGISTRAR
<br />SAH BHNENKAMP
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 10149
<br />w
<br />E
<br />2
<br />1. DECEDENTS•NAME (First, Middle, Last, Suffix)
<br />Kimberley Sue Engel
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />July 31, 2021
<br />4. CITYAND STATE OR: TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Red Cloud, Nebraska
<br />7. SOCIAL, SECURITY NUMBER
<br />505-74-7353
<br />5a. AGE - Last Birthday''
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. PITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand ISland 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />634 N. Custer
<br />9b. COUNTY
<br />Hall
<br />105, MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. PATHER'S-NAME (First, Middle, Last, Suffix)
<br />Darrell Rork
<br />13. EVER IN U.S- ARMED`FORCES?
<br />(Yes, No, or Unk.) No
<br />Give dates of service if Yes.
<br />66
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH No., bay, Yr.)
<br />September 15;;1954
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY l„1MIT$
<br />M YES ❑ NO
<br />104. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Danny Eugene Engel
<br />12. MOTHER'S -NAME (First, Middle,
<br />Monica Martha Kozial
<br />14a. INFORMANT -NAME
<br />Danny Eugene Engel
<br />Maiden Surname)
<br />14b. RELATIONSHIP TODEC.EDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />© Burial ❑Donation
<br />ta Cremation [Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.):
<br />August 4, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Lincoln Cremation Service
<br />CITY / TOWN
<br />Lincoln
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING 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 />18. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter 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 />al Complications of advanced ileus
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />5 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, s b)
<br />any, leading to the causelisted
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EntathoUNDERLnNOCAust c)
<br />(disease or injwythat inaiatad
<br />the events resulting in death)
<br />LAST
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18, PART B. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Seizure disorder, obesity, chronic kidney disease, hypercapneic respiratory failure, congestive heart failure, atrial flutter
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER: CONTACTED?
<br />® YES 0 NO
<br />20. IF FEMALE:
<br />, ® Not preenentwta+inpasf year
<br />❑ Pregnant *Sete of death
<br />❑ :Nal pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ .Unknown if pregnant within the past year
<br />224. DATE OF INJURY (Mo.„ Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER QF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />© Passenger
<br />❑Pedestrian
<br />❑ Other (specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑NO ..
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 31, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 2, 2021
<br />23c. TIME OF DEATH
<br />04:10 PM
<br />Id. Ta the beat of my knowledge, death occurred at the time, date and place
<br />and due to theeause(s) stated. (Signature and Title)
<br />Jennifer C. Harney, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES &I NO 0 PROBABLY 0 UNKNOWN
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<br />Igr
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<br />21 8
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<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIPCODE
<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 />the: Snit, date and place and due to the cause(*) stated. (Signature and Thiel ...
<br />26a. HAS ORGAN OR TISSUE r • ATION BEEN CONSIDERED?
<br />❑YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a la NO 0 YES
<br />0 N
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer C Harney, MD, 609 0 Street, Aurora, Nebraska, 68818
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 8, 2021
<br />1
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