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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 />2/17/2021
<br />LINCOLN, NEBRASKA
<br />2021( 9370
<br />6 )_
<br />4.
<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 />21 02042
<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. < I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Harlan Ray Puncochar
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Ma, Day, Yr.).
<br />February 3, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Se. AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />6e. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo:, Day, Yr.)
<br />Burwell, Nebraska
<br />(Yrs./
<br />87
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 16, 1933.
<br />7, SOCIAL SECURITY NUMBER
<br />506-38.6768
<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 />3070 St. Paul Road
<br />❑ ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<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 />3070 St. Paul Road
<br />Be. APT. NO.
<br />8f. ZIP CODE
<br />68801
<br />fig. INSIDE CITY LIMITS
<br />❑ Yes ® N©
<br />10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name'
<br />Anne Neville
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />George Puncochar Anna Petska
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) Yes 04/13/1953-04/12/1957
<br />14a. INFORMANT.NAME
<br />Anne Puncochar
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />II Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Mo., Day, Yr.)
<br />February 8, 2021
<br />Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL
<br />Curran
<br />HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Funeral Chapel, 3005 S. Locust St., 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 />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 CAU$E «'10.1 a)Significant Interstitial Lung Disease, Asbestos Related ' :
<br />(Neese Of condition running
<br />onsetto death
<br />Years
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any,leading to the caws listed
<br />line
<br />onset to death
<br />on a.
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYNIi 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, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED'?
<br />Iii] YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑Accident ©Pending investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Myer/Operator
<br />❑ Paesenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />❑- Not pregnant, but pregnant within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />suicide Could not W determined
<br />❑ ❑
<br />0 Pedestrian
<br />0 Other (specify)
<br />21d. WERE AUTOPSY: FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Ma., 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. CITY/TOWN STATE ZIP Cope
<br />146
<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 />February 9, 2021
<br />24b. TIME OF DEATH
<br />Approx. 09:45 AM
<br />'
<br />�
<br />0
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 3, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />11:50 AM
<br />$
<br />tad. To the beat of lily knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />24.. On the basis of ecemination and/or Investiga Ion, In my opinion death weaned et
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)::
<br />Williamette Gallagher, County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES 0 NO : 0 PROBABLY ® UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO Q YES ONO'
<br />27 NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Williamette Gallagher, County Attorney, 231 S Locust
<br />Street, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE��� �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />February 16, 2021
<br />
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