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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 />12/17/2021
<br />LINCOLN, NEBRASKA
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<br />20220028.
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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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marc Linn Sundermeier
<br />21 17327
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hot Springs, South Dakota
<br />2. SEX
<br />Male
<br />55. AGE - Last Birthday
<br />(Yrs.)
<br />62
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 1, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />508-86-7321
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />4115 Iowa Avenue.
<br />8a PLACE OF DEATH
<br />HOSPITAL I❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />June 6, 1959
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />Hospice Facility
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Bb. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d ;STREET AND NUMBER
<br />4115 Iowa Avenue
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />89 INSIDE CITY LIMITS
<br />1 I YES NO
<br />10&
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 WIdowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (Fleet, Middle, Last, Suffix)
<br />Gerald Sundermeier
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service B Yes.
<br />(Yes, No, or Link.) No
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Marnie Schaper
<br />i12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Nancy Owens
<br />14a. INFORMANT -NAME
<br />Marnie Sundermeier
<br />15. METHOD OF DISPOSITION
<br />O Burial ❑ Donation
<br />Cremation ❑Entombment
<br />❑ Removal ❑ Other (Specify)
<br />lea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Sb. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />December 12.2021
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfet Funeral Home. 1123 W. 2nd, Grand Island, Nebraska for
<br />Other (SDecifVL,
<br />17b. Zip Cod*
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events- -diseases, 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 N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pulmonary Hypertension
<br />IMMEDIATE CAUSE (PINE
<br />disesea or and)ion resulting
<br />in death)
<br />Sequentially list conditions, N
<br />any, MCSng to the Cause luted
<br />on line a.
<br />Enteritis UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />onset to death
<br />Minutes
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />a,
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<br />B.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />RI YES ❑ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant Within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES gl NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ 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 sits, 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.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23e. TIME OF DEATH
<br />2214. To the beat cif.rity knowledge, death occurred at the time, date and place
<br />sad due to the cause(s) stated. (Signature and Title)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 11, 2021
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Approx. 12:15 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />December 1, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />12:55 PM
<br />24e. On the basis of examination and/or investigation, In my opinion death ooeunsd at
<br />the time, date end place and due to the cause(s) stated. (Signature and TNN)
<br />Benjamin W Shanahan, Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 14 NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Benjamin W Shanahan, Deputy County Attorney, 231 South Locust St, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES j NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />6k-4,2.11-7Bd> /7koz.4rrt
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 15, 2021
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