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<br />STATE OF NEBRASKA
<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 />BATE OFISSUANCE
<br />1/5/2022
<br />LINCOLN, NEBRASKA
<br />vomia
<br />202200733
<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 18266,
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dale Dean Krueger
<br />2. SEX
<br />Male
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ayr, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 28, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 14, 1930
<br />?. SOCIAL SECURITY NUMBER
<br />507-34.7415
<br />8b. FACILITY -NAME (ff not Institution, give street and number)
<br />The Villa at Crown Pointe
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED LIVING
<br />Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Omaha 68124
<br />I8d. COUNTY OF DEATH
<br />Douglas
<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 />1417 Mansfield Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDECITY�-LlIMITS;;:
<br />YES U NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Charlene Fay Bartley
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Huge Krueger
<br />12. MOTHER'S -NAME (First, Middle,
<br />Johanna Van Boening
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 12/30/1950-10/29/1954
<br />14a. INFORMANT -NAME'
<br />Charlene Fay Krueger
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑, Cremation' 0 Entombment
<br />❑'Removal ' 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Christal M. Reineke
<br />16b. LICENSE NO.
<br />1449
<br />16c. DATE (Mo., Day, Yr.)
<br />January 7, 2022
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Trinity Lutheran Cemetery
<br />CITY /TOWN
<br />Blue Hill
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Peters Funeral Home, 302 Second Street, PO Box 181, St. Paul, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1Tb. ZIGCode
<br />68873
<br />18. PART I. Enter the chain of events- -diseases, Injuries, orcomplications-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 />IMMEDIATE CAUSE (Fina& < a) Debility
<br />disease or tbnditiOn reeuhing
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the cause fisted
<br />on lint a.
<br />Enter the UNDERLYING CAUSE
<br />(dieaase'or injury' that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Thalamic Stroke
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Year
<br />onset to death
<br />1 Year
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART it. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Vascular Dementia; Hypertension; Coronary Artery Disease; Diabetes
<br />onset to death
<br />19. WAS MEDtCAL£XAMINER 's
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF.FEMALE::.
<br />❑ Not pregnant within past year
<br />❑ Pregnant Maine of Wath
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant. but pregnant 43 days to 1 year before Wath
<br />❑ Unknown if pregnant within the past year
<br />22a, DATE OF INJURY (MO: Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Penang Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. if TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ 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 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify);
<br />22d. INJURY AT WORK?
<br />El YES ;,❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF IN3URYI' STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />P CODE
<br />c
<br />M
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 28, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 28, 2021
<br />23c. TIME OF DEATH
<br />12:45 PM
<br />224, Tethe beat of my knowledge, death occurred at the time, date and place
<br />and due lb t+M Cause(e) stated. (Signature and Title)
<br />Clayton J. Hoberman, MD
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. on the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature anti Tide)
<br />A
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO Q PROBABLY El UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Clayton J. Hoberman, MD, 11207 W Dodge Rd Omaha, Nebraska, 68154
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 30, 2021
<br />
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