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<br />STATE OF NEBRASKA
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<br />WHEN 7741S COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF TILE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITALRECORDS OFFICE, WHICH !S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE
<br />DC 1$StJ tWCE
<br />.....................................
<br />2/24/2022_
<br />LINCOLN, NEBR K
<br />202202928
<br />L/I :,,tie , ., a'1
<br />SARAH BOHNI;NKAMP
<br />ASSISTANT STATE REGISTRAI
<br />DEPARTMENT OF IIEALTH
<br />AND HUMAN SERVICES
<br />t~
<br />l3BCEDENT'i NAME (First, Middle,
<br />William <F Coleman
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />4. CITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Suttlerland; Nebra k
<br />I. aCCI A# sedUkt Nttiu
<br />05-S8-8894
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />b. FACILITY
<br />o itraet a,..d`Mei CI) a,
<br />77
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa. PLACE OF DEATH
<br />HOSP1TAL [f inpatient
<br />U ER/Outpatient
<br />DOA,
<br />Gateway Se
<br />8c. CITY OR TOWN:. flF pESTH (Include Zip Code)
<br />1 l i rr.0)n 68504
<br />9a. RESIDENCE -STATE
<br />Nebraska:::
<br />9b. COUNTY
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Lincoln.
<br />HOURS
<br />MINS.
<br />22<02161
<br />3. DATE OF DEATH:(Mo.; Day, y
<br />February 8, 2022
<br />6. DATE OF BIRTH (Mo., Day,'Yr.)
<br />NOver
<br />OTHER 0 Nursing Home/LT
<br />0 Decedent'st
<br />® Other (Spec
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />;9di::8TREETAND NUMBER:>,
<br />225 N. 58th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68504
<br />fb6 t (TY UMr('•$;:
<br />ES O :iQ
<br />1Oa.'MARITAL STATUS AT,
<br />Married, but sen
<br />OF DEATH 0 Married
<br />9dowed 0 Divorced 0 Unknow
<br />Never Married
<br />Ob. NAME OF SPOUSE (First,
<br />Corrine Roseland
<br />Middle, Last, Suffix) If wife, give
<br />Mari
<br />AIV
<br />Go
<br />ddle;
<br />Last, Suffix)',
<br />12 MOTHER'S.N
<br />Augusta
<br />AME (First, Middle,
<br />Ehlers
<br />Malden
<br />1
<br />u
<br />13. `EVER IN US ARMED!
<br />(Yee; No, or Unk.) No
<br />CES?'Give ` dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />Barbara Lewien
<br />14b. Rt
<br />Dat
<br />e
<br />EOEN ,
<br />16. METHODOF.DISPOSITION
<br />j Buriat Q Dottolon
<br />'Cremation 0Etitontbment
<br />Q Rergoval ' (] Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (M4 , D#y;?Yr.)
<br />February 1 ;202.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Colonial Chapel Cremation Center
<br />172 FUNERAL;HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Bttds: man Funeral Home and Cremation Services, 2104 Broadway Scottsbluff, Ne
<br />Lincoln
<br />braska,
<br />CAUSE OF DEATH (See Instructions and examples)
<br />It. PART I. Enter the chain ole giants dlaeelms, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reSphetory arrest or vanftiguiar fib 'Nation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />EDIATE CAUSE:
<br />) Respiratory Failure With Hypoxia
<br />;iiaTA9
<br />Nebraska
<br />mRAh tA'tECAUSEtF(nat
<br />dt"intse of aendttlan read(ang
<br />In death),
<br />Sequentially list conditidns,:if
<br />:enyeittedtetg to thp:eatifire teekti
<br />On line a
<br />art. Erdetthe tjteb VINGcALBE
<br />O (dIseass or injury:thet IMtiatsd.>
<br />the events resulting In death).
<br />LAST •
<br />16 PARTn OTHER St
<br />PerkinSOn s #;lace.
<br />IF.PEMALE;
<br />-'F set ivagnaAt.:vatlltilpt
<br />Pre t1ent et mite e111et tb
<br />0 'Nin pregnaiH but pregnant within 42. days of death' 0
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Dementia with Lewy Bodies
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />)
<br />NIFICANT CONDITIONS -Conditions contributing to the death but not tee
<br />art Disease
<br />ha underlying cause given In PART I.
<br />.::tetknhe n lf.Ptegeten *thin the Past ?est
<br />224 PATO QF EN:..3ti (Mo Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural 0 Hamkide
<br />Accident ❑Pending hweetigafion
<br />0 Suicide Could not be determined
<br />21 b.
<br />F TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />Odver/Operator' - y® /i
<br />El Passenger
<br />0 Pedestrian.. 21d. WERE AUTOPSY tlNj s.VA(LABCt9
<br />❑ Other (Specify) TOCOMPL6 •CAUSE AFDEA�TN ,•.., s
<br />D vas _.
<br />22b. TIME OF INJURY
<br />226. PLACEINJURY-At
<br />o, farm, stteet,-factory, office building, construct'l
<br />22d. -INJURY AT1
<br />i] YE5
<br />00o
<br />CRIBE 'HOW INJURY OCCURRED
<br />Ofi INaIURY•.8TREET 8 NUMBER, APT.NO. CITY/TOWN'
<br />123a, DATE OF fEATH (+go., Day, Yr.)
<br />February 8, 2022
<br />STATE
<br />P Qt3DE::
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 10.2022 08:00 PM
<br />d: TAR* beat Of rO enowledge, death occurred at the time, date and place
<br />entduetettbr Oause($stated. (Signature and Title)
<br />Heather L Talbott, APRN
<br />.' DID TOBACCO USE 'CONTRtBUTE'TO THE DEATH?
<br />4-
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)! 24d. TIME PRONOUt ..DEAD
<br />24e. On the basis of examination and/or Investigation, In my.
<br />the time, date and place end due to the sensate) stated. (e1
<br />ki( YES ND 'PRr<i6ASLY ®UNKNOWN
<br />? HAMS, TITLE AND ADOR S OF
<br />CERTIFIER (Type or Print
<br />Neattler 4''Talbott, APRN, PO Box 22359, Lincoln, Nebraska, 68542
<br />26a. HAS ORGAN, QR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES
<br />26b. WAS CONSENT 0RANTBG3
<br />Not Applicable if 26ais
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISYRAR (Mb., Day, Yr.)
<br />February 11, 2022
<br />
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