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<br />STATE OF NEBRASKA
<br />d,IPrl%� r1,h461ddAJ1 v sII '. Ir „ ' ..... . r r'rlt)n1�i%YIr11rIN11 b�lz� 'r ��ll 11�ifi% u I I/ il�llAltlN�� ��r
<br />kw•.,tylyll(adaaa> .,... ,Arr , etlttllrrflfaa (u(NIPIr,3 a, ter tl
<br />W#IEN!THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, iT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE CEPYOF T `HE ORIGINAL RECORD ON FILE WITH THE NEBRASKA `' DEPARTMENT OF HEALTH AND
<br />HUMANSERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />............... ....... .......
<br />i)))iliysl�i�l(t ,d4�eetrlq
<br />I)llll tn�,ll if(
<br />3/312022'
<br />INCOLN, NEBPA$K4
<br />202201
<br />Amended
<br />t
<br />EDENTti-NAM!# ;(#`
<br />f� Linn S.tre:
<br />SARAH BOHINENKAMP
<br />ASSISTANT STATE REGIST
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OFDEATH
<br />ala. Middle, Last, Suffix),
<br />Imister
<br />:AND:STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hot $prings, .South Dakota
<br />1 SOCIAL. URITY NUMBER
<br />08-B6 7521
<br />iFAt LITY=NAME (tf itpt Inatltutlo
<br />4115 • Iowa Auenue3
<br />is. AGE - Last Birthday
<br />(Yrs.)
<br />62
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />! lOSPITA [ Inpatient
<br />❑ ER/outpatient
<br />QooA
<br />8c CITY OR TOMB -OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />6et>$TREET,0lp Nt1iiABEft
<br />X118 bta Attenue .
<br />Sb. COUNTY
<br />Hall
<br />10a MARITAL STATUS AT TIME OF DEATH j Married 0 Never Married
<br />Q Married, but separated 0 Widowed p Divorced 0 Unknown
<br /><FATTIER NAMe (Fits#, ' : Middle,
<br />Gerald Sunderni
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DAT
<br />917927
<br />.::(Mo s Elaut::
<br />202")
<br />6. DATE OF MTH (Mo., Day, Yr.)
<br />June 6, '/838
<br />OTHER Q Nursing Home/LTC
<br />OD Decedent's Home
<br />0 Other(SpeWAr)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />6f. ZIP CODE
<br />68803
<br />b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, (Owl maiden name
<br />Mamie Schaper
<br />13 a ERIN 11:5 ARMEO:FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link) NO
<br />METHOD,OF. DISPOSITION
<br />Q Burial : Q Donation
<br />QRemova ©tuner (Specify)'
<br />12 MOTHER'S.NAME (First, Middi
<br />Nancy Owens
<br />14a. INFORMANT NAME
<br />Marnie Sundermeier
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />n,
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Central Nebraska Cremation Services
<br />17a, FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />ADM Funeral Home, 1123 W. 2nd, Grand Island, Nebraska for
<br />GAIT fSaecifttl ,
<br />Gibbon
<br />CAUSE OF DEATH (S
<br />14b. agLATtaiiiiinP TO tittitoiNt
<br />$louse
<br />STATE
<br />Nebraska)
<br />ee instructions and examples)
<br />IL PART L Enter the chain of etlente- aliases, injuries,; or complicetlons.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />i(asplratory arrw, orveipilcidar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />0010044 CAUSE (P1051
<br />lawns or ao0tdttion rasut
<br />in eeatit).
<br />a) Pulmonary Hypertension
<br />ally list condie
<br />laadlnq to.tlq cause::
<br />ori:ltee s
<br />Entertlq UNDERLYING CAUSE
<br />(aiaeae'e`orInktilinatbitt iso.
<br />DUE TO, OR AS A CONSEQUENCE OF:',
<br />b) Diabetes
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />$ "PART NI OT(IER SIGNIFICANT CONDITIONS -Conditions contributing to the death but n
<br />o IF FE ALE:
<br />Net pregnantaMttn{ast:1
<br />Preg,ttnt at -;-:time Af da*Ht
<br />regnant but
<br />pregttard tigMn 42 days of dnth
<br />pregnant, but pregnant 43 days to 1 year before death
<br />lirdntewn lf,:;prig tl1ta11n tits past year
<br />224: 0AT& trUURT (Bo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural Q Namltlde
<br />Accident Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />sainting lei the underlying cause given
<br />22b. IME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />Ti.
<br />18. WAsmf4W4t. EXAMtNS
<br />ORtTACTItD?
<br />DB a to
<br />21c. WAS AN AUTOPSY P1 E0?
<br />YES .
<br />21d. WERE AUTOP$ 'Manna
<br />...ria A. .
<br />TO cositkarrscAUSE OF DEATH?
<br />❑ YES CI NO
<br />22c. PLACE OF INJURY -At home, fhnry street, factory, since building, construction
<br />22e. DESCRIBE NOW INJURY OCCURRED
<br />22f:;LgCAVON OF SUuRY 'STREET & NUMBER, APT.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />b DAT'EStGNED(Mo.,Day,Yr.)
<br />CITY/TOM
<br />k 11
<br />d. 101he babtO rriil'knowledge, death occurred at are time, date and place
<br />Mod dus 10105 causes) stated. (Signature and Tis)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 11, 2021
<br />24c, PRONOUNCED DEAD (Mo., Day;Yr,)
<br />December 8, 2021
<br />.21F *Dee
<br />24s. TIME OF DEATH
<br />Approx. 1 2:18 PM
<br />24d TIME lartospu an
<br />12:55 Pitt
<br />Mo. :Oath* basis of examination endlor Investigation, In syr opines deatannWstriast
<br />thew thee, date and place and due to the counts) stated. angnsaneanttymin
<br />Beniamin W Shanahan, Deputy County Attorney
<br />;S 0103.. AOCO USE C }NTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />t NAME, TIT AND ADDRESS OF CERTIFIER (Type or Print
<br />Benjamin' W Shanahan, Deputy County Attorney, 231 South Locust St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGANIOR T. ISSUE DONATION:' BEEN CONSIDERED?
<br />❑ YES NO
<br />lG ii 8.':..:..
<br />3/3/2022 Items 3, 24d, December 1, 2021 To December 3, 2021
<br />26b. WAS CONSENT GRAMS°
<br />Not Applicable If 26a Is NO Q YES;
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 15, 2021
<br />
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