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<br />WHEN THIS 'i' 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 />6/9/2021
<br />LINCOLN, NEBRASKA
<br />20210854
<br />)15L -'14:i/ 84Akitaltik4.f
<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 />Pursuant 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.
<br />- _ _ - -
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Arr1Old John Sperling
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Mav 23, 2021
<br />4. CI'T'Y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Ashton, Nebraska
<br />(Yrs.)
<br />91
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 26, 1930
<br />T. SOCIAL SECURITY NUMBER
<br />507-38-6306
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC Q Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Central Nebraska Veterans Home
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney' 68847
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Buffalo
<br />9c. CITY OR TOWN
<br />Kearney
<br />9d. STREET AND NUMBER
<br />4510 East 56th Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68847
<br />9g, INSIDE CITY'LIMtT$
<br />al Yes jQ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated E Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Doris Dorrene Rice
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />George 0 Sperling 1
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Belle Kwiatkowski
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk) Yes 02/04/1949-02/03/1950
<br />14a. INFORMANT -NAME
<br />Judy Weinrich
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15, METHOD OF DISPOSITION
<br />lia BUVlat 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />1537
<br />16c. DATE (Mo., Day, Yr.)
<br />May 28, 2021
<br />Cremation ©Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfiel Funeral Home, 1123 W. 2nd, 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 complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibriltation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />E4MEDIATE CAUSE (Mild '; a) Cardiac Arrest
<br />dtaeaee er mermen moulting
<br />in Mehl
<br />onset to death
<br />24 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b) Coronary Artery Disease
<br />any, leading ta:the MOO listed
<br />cat tine a.
<br />- onset to death
<br />10 Years Pius
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Injury that initiated
<br />onset to death
<br />the events resulting in Math) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18, PART 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 />❑ YES ENO
<br />20. IF FEMALE:
<br />Q Notpregnant within past year
<br />0 m at dnle of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />El Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NOPte
<br />❑ Not pregnant, but pregnant within 42 clays of death
<br />❑ Not pregnant, but pregnant 42 days to 1 year before Math
<br />Q Unknown if pregnant within the past year
<br />suicide ❑could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 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, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />OYES <ONO>
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. C1TY/TOWN STATE ZIP CODE
<br />E'0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 23,2021
<br />3 _
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 .1", i,Eunei,20.21
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />06:06 PM
<br />E�
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />B
<br />H
<br />i
<br />23d. To the beat of my knowledge, death occurred al the time, Mb and place
<br />and due to the causes) stated. (Signature and Ties)
<br />Brad Rodgers, MD
<br />'a' W
<br />.8 G LI' 5
<br />12 8 is
<br />24e. On the basis of examination and/or Investigation, in my opinion Math occurred at
<br />the tine, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DtD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES <IR NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERER?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO O YES Q NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Brad Rodgers, MD, 4510 E 56th St, Kearney, Nebraska,
<br />68847
<br />28a. REGISTRAR'S SIGNATUREa�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 2, 2021
<br />
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