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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 />9/18/2020
<br />LINCOLN, NEBRASKA
<br />202108543
<br />AA
<br />/-:Hrarf_t-iy:%f'-
<br />SARAH BOHNENKAMP f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />TIFICATE OF DEATH
<br />20 12132
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are flied 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 />Karen Marie Cloud
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />July 6, 2020
<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 />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Schuyler, Nebraska
<br />(Yrs.)
<br />49
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 12, 1971
<br />7. SOCIAL SECURITY NUMBER
<br />508-86-6148
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b.-FACILITY-NAME'((If not Institution, give street and number)
<br />CHI Health St. Francis
<br />E ER/Outpatient ❑ Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<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 />2912 West 16th Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />90. INSIDE CITY LIMITS`
<br />al YES ❑ 'N©
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Timothy Cloud
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Anton Gall I
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Regina Houfek
<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 />Sue Ludeman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />15. METHOD OF
<br />E Burial
<br />DISPOSITION
<br />©Donation
<br />16a. EMBALMER -SIGNATURE
<br />Nicholas D. Tank
<br />16b. LICENSE NO.
<br />1478
<br />16c. DATE (Mo., Day, Yr.)
<br />July 11,2020
<br />Cremation
<br />Removal `
<br />0 Entombment
<br />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 />13. PART I. Enter the chain of events- di , injuries, or complications -that 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 on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (final a) Pulmonary And Cerebrovascular Thromoembolism
<br />diseese or condition resetting'
<br />onset to death
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, N b)Deep Venous Thrombosis Of Left Leg
<br />any, leading to the cause listedon
<br />onset to death
<br />line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enda the UNDERLYING CAUSE C)
<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 />18. PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART i.
<br />Obesity
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:
<br />®s Not pregnant within past year
<br />CI Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />❑Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />E YES ❑ NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />El Not pregnant, but pregnant 43 days to 1 year before death
<br />0 unknown if pregnant within the past year
<br />Suicide Couldnot be determined
<br />El Suicide
<br />❑Pedestrian
<br />ElOther (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />E YES L:J NO
<br />22a. DATE OFINJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm,; street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 31, 2020
<br />24b. TIME OF DEATH
<br />09:29 AM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />July 6, 2020
<br />24d. TIME PRONOUNCED DEAD
<br />09:29 AIVI
<br />23d, To;the hest of my knowledge, death occurred at the time, date and place
<br />and due -lathe cause(s) stated. (Signature and Title)
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(a) stated. (Signature andTitle)'
<br />S. Alex West, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E 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 />S. Alex West, Hall Deputy County Attorney, 231
<br />S. Locust, Grand Island, Nebraska, 68801 '
<br />28a. REGISTRAR'S SIGNATURE
<br />/
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2020
<br />
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