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ufftvalDiu Vit!' lId Atka, RfMRfk$£i3lti4RLHn4tt7Y(aWf199X%L>< 931D:>. §ax2st6yAd3� iv"'�' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 10/14/2021 LINCOLN, NEBRASKA 20210887[1 /L , th.et for SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES R 21 13426 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, ' 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Emm8 Nettie Hill 2. SEX Female 3. DATE OF DEATH (Mo.; Day, Yr.) September 30, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) Alda, Nebraska (Yrs.) 81, MOS. DAYS HOURS MINS. April 13, 1940 7. SOCIAL SECURITY NUMBER 506-50-7685 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC CI hospice Facility 8b.'FACILITY•NAAME If not Institution, give street and number) 3228 West 18th. Street ❑ ER/Outpatient ® Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN QF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d, STREET AND NUMBER 3228 West 18th Street 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ®''Es 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Verne L Hill 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Schlieker 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Grace Campbell 13. EVER 1N U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Verne L Hill 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Q>Burial ❑Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) October 4, 2021 Q Cremation ❑ Entombment Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for Other (Specifv), . , 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 11. PART I. Enver the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final ' a)Alzheimer's Dementia disease tit condition resulting: onset to death 6 Years In Watt) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If b)Arteriosclerotic Vascular Disease any, leading to the cause listed on tine s. onset to death 10 Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or Injury that nitiated onset to death the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF 0 ❑ FEMALE: Not pregnant: within past year Pregnant at Nine of death❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? YES NO ❑> Not pregnant, butpregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑suicide ❑Could not be determined Pedestrian ❑ Other (specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 224. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP cope S 1 23a. DATE OF DEATH (Mo., Day, Yr.) September 30, 2021 Tobe completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 11 1. is tx z 23b. DATE SIGNED (Mo., Day, Yr.) October 4, 2021 23c. TIME OF DEATH 09:50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD E 4 O G.: 2 33d. To the best Only knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Gary Settie, MD 24e, On the basis of examination and/or investigation, In my opinion death ocdurrelt et the time, date and place and due to the cause(a) stated. (signature4114 TSIs) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES Li] NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR ISSUE . • ATION BEEN CONSIDERED? 0 YES El NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES: 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE ) `- .4 ii'72 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 8, 2021