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<br />WHEN < THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, ' IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDSDATE F
<br />RUSSELL FOSLER
<br />12/13/2019 2 0 2 2 0 2 2 0 8 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 />LINCOLN, NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Colleen Sue Holder
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 2, 2019
<br />4. CITYANb STALE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-38-7148
<br />5a. AGE:. Last Birthday
<br />(Yrs.)
<br />80
<br />5b. UNDER:1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS:
<br />DAYS •
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (MO.,;Day Yr.),;
<br />March 26, 1939
<br />8b FACILITY NAME (If not institution, give street and number)
<br />CHI Health St Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8a RESIDENCE -STATE
<br />Nebraska
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER/Outpatient
<br />DOA
<br />9b, COUNTY
<br />Hall
<br />9a. CITY OR TOWN,
<br />Grand Island``
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />9d. STREET AND NUMBER
<br />722 E. 8th Street
<br />2') iDa. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />. 0 Married, but separated:; 0 Widowed 0 Divorced ❑ Unknown
<br />Last, Suffix)
<br />1,4 11. FATHER'S -NAME (First, Middle,
<br />if)
<br />Thomas Korn
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) NG
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS:`
<br />II YES ❑ NO
<br />IIIb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, givemaiden name
<br />George Lei? Holder.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Hattie Maxon
<br />14a. INFORMANT -NAME
<br />George Holder
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OFD(SPOSITION
<br />0 Burial 0 Donation
<br />® Cremation 0 Entombment
<br />0Removai i0 other#SPecify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />1611. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />December 7, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Gibbon
<br />Central Nebraska Cremation Services
<br />STATE
<br />Nebraska
<br />; 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />o' All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska
<br />v
<br />17b. ZipCode
<br />68801
<br />N'
<br />18. PART 1 Enter the chain of events- -diseases, Injuries, or complications -that directly caudad the aaath.DO NO€ enter terminal events such as cardiac arrest
<br />respiratoryarr@et,or yentriCular fibrillation without showing the etiology. DO NOT ABBREVIATE Elrter only one Cause ora hne Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />i
<br />IMMEDIATE CAUSE a) squamous Cell Rectal Cancer Localized
<br />E diseass or 4011d7ii011 ,esuxing
<br />:RI inaeatAl ..
<br />-0
<br />a
<br />Enter the UNDERLYING CAUSE
<br />D (dise$e or htJ rr trat Initteted':
<br />the events resuhlttg in death)
<br />LASx
<br />CAUSE OF DEATH (See instructions: and examples)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />8egtienlially list cold tions If i' b)
<br />any,le$d,ng tathecauseliated
<br />on linea
<br />APPROXIMATE INTERVAI
<br />onsetto death
<br />3 Months
<br />on
<br />et o death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Chronic Hypoxic Respiratory Failure, Dementia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />0Not pregnant, but Prithin 42 tlatnre death
<br />❑ Nat pregnant, but pregnaegnantnt w
<br />43 days todays 1 year beefo
<br />❑ (N,known if pregnant witnmi the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22i1.1tJURY.AT:WORK?
<br />❑YCS ❑NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could net bedetemined
<br />22b, TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />Pedestrian
<br />Other3Pecifyf
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAI.ABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO •
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO.
<br />DATE Ol- uETH (Mo., Uay, Yr.)
<br />December 2, 2019
<br />CITY/TOWN
<br />STATE
<br />x4a. UArb SIt NED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 3 2019
<br />23c. TIME OF DEATH
<br />10:10 PM
<br />3d. To the best of my knowledge, death occurred at the time, date andplace
<br />and due to the cause(s) stated. (Signature and Title)
<br />•
<br />Ryan1. Crouch, DO
<br />4c. 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 and Title)
<br />• 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE'. DONATION BEEN CONSIDERED?
<br />❑ YES MI NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan A. Crouch, DQ, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />ZSa. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(MO.,Day, Yr.)
<br />December 10, 2019•
<br />
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