|
ggat 1; 114
<br />fA f 'tttttyANptt tfttffffi7,'Iifffifftg,tfmtlitiNfgat.
<br />am4l sav#:a gt 1(lyi,%dlstd.rrApo11;1$4ii liimg32k7sfta 44L`1))1
<br />�:. i4QYf/�ffta5!!K> t4/r/fj1i,1111111 •
<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 />9/25/2020
<br />LINCOLN NEBRASKA
<br />202108199
<br />r 7
<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 />20 12444
<br />`o
<br />E
<br />m
<br />>ts
<br />0
<br />d
<br />5
<br />Int
<br />2
<br />c
<br />S;
<br />E
<br />.3
<br />to
<br />et
<br />12
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Donald Dean Kiser
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />September 9, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St, Paul, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />87
<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 />April 11, 1933
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-1078
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />1617 N. Engleman Rd
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER,
<br />1617 N. Englernan Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated I Widowed 0 Divorced 0 Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Hospice Facility
<br />90. INSIDE CITY LIMITS
<br />Q YES 50 NO
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Kiser
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Rosie Jerabek.
<br />13. EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Kathryn Reimers
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />El Burial 0 Donation
<br />❑' Cremation; 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16b. LICENSE NO.
<br />1439
<br />16c. DATE (Mo., Day, Yr.)
<br />September 18, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chitin of events- -di , injuries, or complications4hat directly caused the death. BO 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 Ilne. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Undetermined Natural Causes
<br />IMMEDIATE CAUSE (Final
<br />disease orcondslon resulting
<br />in death(
<br />Sequentially list conditions, if
<br />any, leading to the cause: listed
<br />on line a.
<br />Entet: the UNDERLYING CAUSE
<br />(disease or injury'that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />Congestive Heart Failure
<br />19. WAS MEDICAL EXAMINER 's
<br />OR CORONERCONTACTEO?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within peat spar
<br />0 Pregnant at time death
<br />❑
<br />Not Prngnalit: but pregnant in dt M
<br />❑ Not pregnant, but pregnant 43withdays todays 1 yearof tlaabefore death
<br />❑ Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑.Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 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 />0 YES E' NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ 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, ata. (Specify}
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO ,..
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION- OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />22d. TO the best of my knowledge, death occurred at the time, date and place
<br />and due to -the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE ZIP{CODE p.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />September 10, 2020
<br />24b. TIME OF DEATH
<br />Approx. 04:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />September 9, 2020
<br />24d. TIME PRONOUNCED DEAD
<br />07:15 AM
<br />24e. On the: basis of examination and/or Investigation, in my opinion death ocfumd at
<br />the time, data and place and due to the eau e(s) stated. (Signature and Tale)
<br />Dave Medlin, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />27, NAME, TITLE; AND ADDRESS OF CERTIFIER (Type or Print
<br />Dave Medlin, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE 3
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 21, 2020
<br />
|