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<br />.144.10P-' Mitt STATE OF NEBRASKA
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<br />WHEN .THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,.. IT CERTIFIES THE DOCUMENT BELOW TO
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<br />lor•::14 TRUE:COFY.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 />2/28/2022
<br />LINCOLN, NEBRASKA
<br />2 0 2 2 0 2 2 6
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<br />.:A
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF IlEALTII
<br />•.• AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />771.,I
<br />pacsoeNrs*Aros.(Fir:t, Middle, Last, Suffix)
<br />'
<br />Norman :::::Lotits SOdomka
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE r.-1,kTERRITORY, CP. FOREInN C3UNT7r: QF DIRTH
<br />Columbus,.Nebraska
<br />7 SOCIALIEOURITY NUMBER
<br />508-50:46:T56
<br />• :F.6.1.• 8b. FACILITY -NAME (IVririt Institution, give street and number)
<br />908 South Oak Street
<br />ua. AGE - Last Birthday [5b. UNDER 1 YEAR
<br />22 02877
<br />2. SEX 3. DATE OF DEATH (Mo.,
<br />Male January 28 7022
<br />5c. UNDER 1 DAY 6. DATE OF BIRTfflkAo., DayYr.)
<br />(Yrs.) MOS.
<br />78
<br />DAYS
<br />8a: PLACE OF:DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Ou patient
<br />0 DOA
<br />HOURS
<br />MINS.
<br />May 1, 1943
<br />OTHER 0 Nursing Homo/LTC
<br />g Decedent's Home
<br />0 Other (Specify)
<br />0:Hespice..:Facility •
<br />8c. CITY OR TOWN OF •DEATH (Include Zip Code)
<br />• :
<br />• :74•: Grand -Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND''NUNIBER•
<br />9o.8 SOuttOalk Street
<br />10a. MAIpTALATATUp AT TIME OF DEATH E Married 0 Never Married
<br />a) 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9e. APT. NO.
<br />9f. ZIP CODE SiAN:810E crrYUMITS
<br />68801 • YES; 01)10
<br />Last Suffix) If wife, give maiden name •••• •••
<br />lob. NAME OF SPOUSE (First, Middle,
<br />Barbara Ann Lovenburq
<br />. ..e..11. FATHER'S -NAME First, Middle, Last, Suffix)
<br />• Norman ..John Sodomka
<br />4. 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />u 15. METHOD OF DISPOSITION
<br />Burial ['Donation
<br />Cremation Ll entombment
<br />u Removal Other (Specify)
<br />I12. MOTHER'S -NAME (First, Middle,
<br />Norma Louise Severe
<br />14a. INFoRmANT-NAME
<br />Barbara Ann Sodomka
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT:::.
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />18c. DATE (Mo., Day,
<br />r1
<br />February 2, 202Y2
<br />16d. CEMETERY, CREMATORY OR OTHER LOCAllON
<br />Westlawn Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All FaithsFuneral Home, 2929 S. Locust Street, Grand Island, Nebraska•
<br />17b. Zip Code
<br />68801
<br />v • * • • ,•11 t • • •
<br />Is. PART I. Enter the Chafn et events- 4leseees, Infer's., or complications4tiat directly caused the death. DO NOT ether terminal events such es 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 tl necessary.
<br />IMMEDIATE CAUSE:
<br />•IMMEDIATEDAUSEfFinal a) unknown natural causes
<br />disease or condkion resulting
<br />in dea(h) •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, leading to the cause listed
<br />on lined.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />5015 11> c)
<br />(disasteror Injury:that lithietild
<br />the events resulting M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />18.PART9,07UER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not i'.0ailiting iri theunderlying cause given in PART I.
<br />diebetes, kidney disease
<br />APPROXIMATE INTERVAL
<br />onset fP';FIFalti>,
<br />MinUfiS:
<br />onset to death
<br />onset 10,0enth:
<br />onset to death
<br />19. WAS MEDTD*ti(EXOANEWC
<br />OR CORONSKOONTACTEDI
<br />E YES 0 NO
<br />• 20. IF FEMALE; ,,,
<br />Not preonaet withiApastyner
<br />crlf!,:regrti,lfit attitp* of ddath•
<br />0 •Netpregnailt but praenant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown ItpregnentiwithIn the past year
<br />22a.:',DATE: OF INAIRYIMO.;;EOay, Yr.)
<br />'4i •
<br />• 02f,:40CATION,OP INA/RY 'STREET & NUMBER, APT.NO.
<br />1 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />tio Natural 0 Homicide
<br />0 Accident 0 Pendingn"ig
<br />0 Suicide 0 Couldoltbe8dteteaft°Th
<br />rinined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 „Driver/Operator
<br />0 :Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES 5114)16
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE.
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At herne, Wm, street, factory, office building, construction site, et0Specify1:
<br />YES DNO
<br />.77.;
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<br />8 t
<br />Vu.
<br />g u 2
<br />*CI
<br />CITY/TOWN
<br />STATE
<br />23a. DATE OF DE
<br />-ATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />g
<br />g
<br />23c. TIME OF DEATH
<br />23th:inthe beirtrif ithi'knowledge, death occurred at the time, date and place
<br />end atie]lo.:1Miseis) stated.
<br />(Signature and Title)
<br />25. DIDTOBACCO USEDONTRIBUTE TO THE DEATH?
<br />DYES '.0 PROBABLY El UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 23, 2022
<br />24b. TIME OF DEATH
<br />Approx. 03:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />January 28, 2022
<br />24d. TIME PRONOUNCED DEAD
<br />0500 AM
<br />24e. On thettheis of examination and/or investigation, M my opinion deatknceurrethst
<br />• the tirtierlate and place and due to the cause(s) stated. (Signature aritlAnia)
<br />Garrett Schroeder, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES E NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Garrett Schroeder, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO •:]:0 yaa
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 24, 2022
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