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<br />NAM 476414 I em
<br />q 31 1/Beira
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<br />STATE OF NEBRASKA
<br />�1FR et12141YHN�TNm" *;tZi }?➢r mtr4tWNiWr���rr�ItT
<br />is t�a(Q)I,tirtl� ,
<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 />12/21/2021
<br />LINCOLN, NEBRASKA
<br />202200804
<br />5'01-406 f4-44,
<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_OP DEATH
<br />1,.DECE:OEHTI3NAME (FII, Middle, Last, Suffix)
<br />Maril n Joan Fools
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRT 0.i
<br />Kearney, Nebraska
<br />s.SOt..:ALsSECURITY NUMBER
<br />505-58-2382
<br />Sb. FACILrTY4NAM! pf not Institution, give 1tnst ,md numbed
<br />12, Kennedy Place
<br />tae CITY :OR:TOWN OF DEATH (Include alp Cade)
<br />Grand Island 68803
<br />911. RESIDENCESTATE
<br />Nebraska
<br />*it SiRear AND NUMBER
<br />512 Kennedy Place
<br />to. COUNTY
<br />Hall
<br />2. SEX
<br />Female
<br />4 L . 2
<br />3. DATE OF DEATH (Mv AINN,Yr.)
<br />July 16, 2014
<br />. AOE.L est Birthday
<br />(Yrs ). 's
<br />69
<br />em. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />mos
<br />DAYS
<br />Str. PLACE OP DEATH:
<br />SAL; 0 ehpattrmt
<br />0 1fad
<br />0 toot
<br />9c. CITY OR TOWN
<br />Grand island
<br />a.. APT
<br />HOURS
<br />MINS.
<br />S. DATE OF BIRTH (Mo.. Day, Yr.)
<br />atm O Nurses ManelLTC
<br />[Di O.aadent•s HORN
<br />O(3010(91l.aRy)
<br />9d. COUNTY OF DEATH
<br />Hall
<br />K ZIP CODE
<br />68803
<br />p Hotlpks FRAI ly
<br />1M. MARITAL STATUS AT TIME OF DEATH Married 0 Nevar Monied 1011. NAME OF sr0use (First, Middle. Last, Suffix) R Wfa, give maiden flan..
<br />MONK bed separated O Widowed 0 Dtvoroed ❑ Unknow/: Roger reale
<br />11. FATHER'S41AME (Fest. Middle. Last. Suffix)
<br />Howard Theodore Holthusen
<br />13. EVER IN U.S. ARMED FORCES? Give dater of service R Yea
<br />(v u, tin, enUek) No
<br />1S. MSTHOD OP tuposmoo
<br />[Dhow 00onia.
<br />OCa0„na plus,.,,,
<br />Oi
<br />11..114FORMANT.NAME
<br />Roger Fools
<br />10..E LY&R-SIGNA
<br />c���
<br />tad. C CREMATORY OR 7HER LOCATION
<br />12.MOTHER•S,MAME (Feat, Middle, Maiden Seasons
<br />Gladys Lorena Lowell
<br />IIp.INSIDE CITYUMITS s:
<br />®Ya 0 N
<br />trait LICENSE NO..
<br />348
<br />1111. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />tae. DATE (NW, Dry, W.)
<br />July 18, 2014
<br />CITY/TOWN
<br />Riverside Cemetery Gibbon
<br />17*. MINERAL: HOME NAME AND MAILING ADDRESS (Street. City or Toem, Boma)
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island. Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />it ',MT L anYr e. • 1110.11.106. MOW., opfrapllooliorn.saes MndA errw*wn 0aa01. 06.110T nor* Nrnunli wont such emits awn.
<br />:IMOialtarf NMI, u wrrtrahrab4IINp. armed *waving los Miaow-_ DO NOT 000REVIA'SIE. nter tint,cro cow w, a link AN *Mend Moe d mammary,
<br />IMMEDIATE CAUSE:
<br />N1MEDUGTE CAUSE (Fife,
<br />dlINeear0Ondtlon resulting a)
<br />In Barth)
<br />1tYi f} 'T"Yt-r-r"Refc
<br />STATE
<br />APPROJStATE1NTERNAL
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />SeguentleIN flat condi ions. N
<br />cest,;leOSS) to 0.. cars. ilebd b)
<br />outfitea.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the uNDERLYSIO CAUSE c)
<br />(assess or 0 *fly the Initiated
<br />ple ay.hw ,,,,„kine la datlt) DUE TO. OR ASA CONBEOUENCE OF:
<br />d)
<br />18. MART N. OTHER SKINIFICANT CONWTIONS$Condalons contr4buttng to the death but not resulting M the underlying eau.. given In PART 1.
<br />20. IF FBMALE;:.
<br />r [leeprepdpnt ar
<br />within past ye
<br />r3Prenwit r time or death
<br />ON of Pregnant, but eminent wNMn 42 days of death
<br />ONot pregnant, but p'Wn+wt 43 days Dot year Neter*
<br />I UrMmewn R pregnant within the past year
<br />3211. DATE OF INJURY (Ma, Ary, Yr.)
<br />Its. MANNER OF DEATH
<br />® Natural tj.: Homicide
<br />l] AuvIdent 0 Pending bryutigalbn
<br />O Subside 0 Celan not be determined
<br />Moth
<br />2211. TIME OF INJURY
<br />m
<br />onset to death
<br />anal to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED/
<br />O YEA fJ NO
<br />21b. IF TRANSPORTATION INJURY 21s. WAS AN AUTOPSY popeaMeo?
<br />Li»rtv«rov.rater OYES I:1,e0
<br />PIIIIDIROW
<br />0 Pedenrien
<br />Q Qther (Specify)
<br />21d. WIIRE AUTOPSY FINDINGS AYAS.MLE
<br />TO COMPUTE CAUSE OF DEATH?
<br />OYES Oso ..
<br />22c. PLACE OF INJURY -At horn., farm street, factory, °Rica Welding, caaatruefba ON, am. (Sp.ery)
<br />'G#JRY AT WORK?
<br />0 YESQtet)
<br />22e. DESCRI80 HOW INJURY OCCURRED
<br />LOCATION OF INJURY - STREET A NUMBER, APT, 410, CI:"VITrtOWN
<br />23s. DATE OF DEATH (Mo.. Day. Yr.)
<br />DATE SIGNED (kb., Day, Yr.)
<br />23c. 780E OF DEATH
<br />23d. To the bast of lay knowledge, dash oaclmod M thefts, date and piece
<br />and due to the c e) Mtdied. Ietgnsture are Tele)
<br />2S: DID TOBACCO 4240
<br />0408 : I NO
<br />TO THE DEATH?
<br />OLY p UIRRI0wo
<br />STATE
<br />24o,DATE SIGNED (Mo., Day, Yr.)
<br />240. TIME Op DEATH
<br />ZIP
<br />PRONOUNCED DEAD (Mo, Day, Yr.)
<br />24d.WPM PRONOUNCED
<br />m
<br />24e. On tits basis M a tembledon and1er elves0gellen. M fly opinion doth a0*Rfad
<br />et toe tens, dab and place and duo to ins cause(s) WMd. (piens dreat.d:DRN):.:
<br />MIAMI
<br />Xs HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 ma
<br />‘400 ,0
<br />tab. WAS CONSENT GRANTED?
<br />Not Applicable If Mt is NO 0 YES NO
<br />27, NAME, TITLE AND SS OF CERTIFIER (Type or PHn
<br />.Jana;, Van Wie M.D. 19
<br />RE,
<br />ARS SIGNATURE
<br />7 West Faidiey Avenue, Grand
<br />Lintit A
<br />stand, NE 68803
<br />FILED SY REGISTRAR (Mo, Day, Yr,'
<br />JUL 18 2014
<br />00
<br />ccD0)
<br />N
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