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STATE OF NEBRASKA •
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/9/2021
<br />LINCOLN, NEBRASKA
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<br />202109658
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<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 />t DECEDENT'SNAME (First, Middle, Last, Suffix)
<br />Kenneth Harold 'Koepke
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Blue Hill, Nebraska
<br />• SOCIA(. SECURITY NUMBER
<br />$05-42-'3951
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />#27 Kuesters Lake
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.:STREET AND NUMBER.
<br />#27 Kuesters Lake 'r
<br />9b. COUNTY
<br />Hall
<br />10a.`MARITAL :STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />85
<br />'Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />0 DOA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />Et Atilit,)9011 09411"
<br />4,01AW ,1 ya�JAer/y
<br />2114786
<br />3. DATE OF DEATH (Mo.,
<br />October 30,i1021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 6, 1936 ..
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g INSiDE DlTY iMITS;>.
<br />YES ®tiD
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Geraldine Elaine Black
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />j Eda Van Boeninq
<br />Harold J ;.Koepke
<br />13. EVER IN U,S..ARMEDFORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/25/1958-01/02/1964
<br />14a. INFORMANT -NAME
<br />Geraldine Elaine Koepke
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD QF DISPOSITION
<br />• ®;Buttal ❑DonaNbn
<br />❑;Cremation, ]Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />16c. DATE (Mo., Day; ;Yr.)
<br />November 5
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART I. Enter the chain of events- dlseaaes, injuries, or complications -that directly caused the death. DO 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 line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) pulmonary embolus
<br />IMMEDIATE CAU6.E (Feial
<br />disease or condlti an reauaing
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on. 1111. a.
<br />Entetthe UINOERLVING CAUSE
<br />(disease of lnjurythat Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)lower extremity deep venous thrombosis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) hypercoagulable state
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)likely colonic malignancy
<br />18. PART 8.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />embolic stroke, mediastinal Lymphadenopathy, atrial fibrillation
<br />17b, Zip Code
<br />68801
<br />1
<br />APPROXIMATE INTERVAL
<br />onset to tdeatt
<br />Days
<br />onset to death
<br />Days
<br />onset to death
<br />Months
<br />onset to death
<br />Months.
<br />19. WAS MEDICAL.:EXAMINER
<br />OR CORONERGONTACTED? •
<br />❑ YES [g] NO
<br />20.1F FEMALE: :.
<br />0 IIIot Pfegnant within pastykar
<br />CIPregnant at time of death
<br />❑ NCtpregnant but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year baton, death
<br />0
<br />,.Unknown 1 pregnant within the past year
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Inyeatigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 30, 2021
<br />CITY/TOWN
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES CI NO
<br />F INJURY;At home, farm, street, factory, office building, construction site,
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 1, 2021
<br />23c. TIME OF DEATH
<br />05:28 PM
<br />23d: Toth* beat of my knowledge, death occurred at the time, date and place
<br />and/Am-Meta ciuse(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES lgi NO ❑ PROBABLY ❑ UNKNOWN
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ecify) •
<br />P CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD..
<br />24e. On the basis of examination and/or Investigation, In my opinion death Doctpredal
<br />tits tin h, date and place and due to the cause(s) stated. (Signature aad tIde)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />6.44-A Bad A erk.a.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES 0 NO.,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 2, 2021
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