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<br />ww/40 THIS ." COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE :A TRUE COP ` OF THE ORIGINAL RECORD'
<br />ON FILE WITH .1 HE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN , SERVICES, VITAL
<br />RECORDS OFFICE, WHiCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDSattgl
<br />•
<br />DATE OFISSUANCE STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />8/31/2017 DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />• •
<br />W.
<br />W
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<br />STATE OF NEBRASKA - DEPARTMENT QF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />t DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Eva Mardell Reher
<br />4 '1i T`fANGSTA')EOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ebrska
<br />Oak,N
<br />7. SOCIAL SECURITY NUMBER'
<br />565-20-7853....
<br />ffikifACILITYMAMElltbffitaffiltution, give street and number)
<br />Gorid:.San fltBrt.Society=Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zap Code)
<br />Grand Island 68803 •
<br />Ea:REStD NGE$TATE
<br />9d. STREET AND' NUMBER"
<br />3990 W. Capital Ave
<br />9b. COUNTY
<br />Hall
<br />Ma. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />CI Morand, but t eparwted;;❑ Widowed 0 Divorced 0 Unknown
<br />11 FATmirsNA iE (First;'. Middle, Last, Suffix)
<br />Otis Francis Bates
<br />13..,EVER IN;U.S.:ARMED:FORCES? Give dates of service if Yes.
<br />(Yes;°No>or urts] No.
<br />Sa AGE;; Last Birthday
<br />firs.)
<br />iiN.. UNDER 9. YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS:
<br />8a PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpent
<br />❑ DOA
<br />DAYS
<br />9 CITY OR Tl}WN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Ma, Day, Yr.)
<br />August 18, 2017
<br />6. DATE OF BIRTHISIo .13ay, ICF;
<br />March 21;1924i
<br />OTHER ® Nursing HorgelLTC
<br />❑ Decedent's Home
<br />0 Other(SpecifY)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />232
<br />9f. ZIP CODE
<br />68801
<br />co Facility
<br />9g. SDE CliVLIMrtS
<br />® YES ❑ NO
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />DDnzei .Rudolph Bernhardt:<. Reher
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Verda Alice Sherwood
<br />14a. INFORMANT -NAME
<br />Doniel Rudolph Bernhardt her
<br />00090 0.!.:0060(710#
<br />POSIT)ON
<br />❑ Buiriat ❑Donation
<br />cremation 0 Entombment
<br />} R:0irtti4 ;0 01hert 4apediN),.:
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town State]
<br />All Faiths Funerat Home. 2929 S. Locust Street, Grand Island Nebraska
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b.::LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />t& PARTI. Etter ete;chakt ortveilts- assesses, injurks, or complications -that directly caused the death. rIO NOT entohi4rmiftbd
<br />respirathty mint, prat <itritutair fibrillation without showing the etiology. DO NOT ABBli6WATE. Enter only one pause ee a
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Advanced Age And Progressive Alzheimer's Disease
<br />disease or condition resulting
<br />?I+deatA)::
<br />#aquegi
<br />> any; athngtti i
<br />'On melt >'r
<br />tlaveeea
<br />rel
<br />u
<br />used
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />RLYING CAUSE C)
<br />rytaat,kidaettc04.
<br />Nnotd,M.W
<br />: DUE TO, OR AS A CONSEQUENCE OF:
<br />1)
<br />eseats such as cardiac arrest,
<br />ens. Add additional Tines If necessary.
<br />14b. RELATIONSHIP TO pacapaNT
<br />Husband
<br />i6
<br />16c. DATE (Mo. Ify 3
<br />August 23, 2017
<br />STATE
<br />Nebtaisk;
<br />17b Zip. od
<br />68801
<br />APPROXIMATE INTERVAI'. >.
<br />Onset
<br />t..400.0.!:.
<br />r
<br />0
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Pulmonary Edema; Chronic Atrial Fibrillation On Anticoagulation Therapy; Coronary Artery. Disease And Chronic
<br />beta rrhyeittls .t The Right Knee.
<br />OIF$EMALE
<br />Not pregnarit>HkNn paet:year
<br />❑ Pregnant at time of death
<br />❑ Not treenan!, Sift pmpoi m wahin 42 days of death
<br />❑ NirE Predhars, bad pragnant::43 days to 1 year before death
<br />❑ Unknown ti ptmgaea* wonky, he past year
<br />22a. DATE dF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide .
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could 1101 be determined
<br />22b. TIME OF INJURY
<br />ilii lF TRANSPORTATION INJURY
<br />Dr ilt/Operator
<br />0 Passenger
<br />opedestrian
<br />other tspeciry)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 1t1
<br />21c. WAS AN AUTOPSY PIERFOFIAAED?i
<br />❑ YES ® No : i
<br />21d. WERE AUTOPSY FI/DINGS AVAILABLE
<br />TO COMPLETE CAU$E 'DEAT#7.;..
<br />❑ YES ❑ Nt7
<br />22c. PLACE OF INJURY -At Mita, farm; street, factory, office building, construction 8
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OlfINJURY - STREET & NUMBER, APT.NO.
<br />a, Dik'r£ Ote'EATH (ilio, Day, Yr.)
<br />AtI #asp 18 201.7:_
<br />S'ftI11 LI M Day, Yr.)
<br />Auoust23, 2017
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />06:40 PM
<br />. To the best of my kndaaedge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and title)
<br />ane A. Mi nail,-tvID
<br />28 DE}'TOBACOi?U$E CONTRIBUTE TO THE DEATH?
<br />armNO Q PR019ABLY 0 UNKNOWN
<br />0
<br />STATE
<br />:24a.1:477IGNED (Mo., Day, Yr.)
<br />IJNCED DEAD (Mo., Day, Yr.)
<br />wiry)
<br />24b. TIME OP DEATH.
<br />24d, TIME P
<br />SIP CODE:,%:
<br />24e. On the bask of examination andior investigation, in my opinion death oacurraf at
<br />the time, date and place and due to the cause(s) stated. (ai9natdrs and Title)
<br />26a. HAS ORGAN OR TISSUE DONATI
<br />27. NAME .TITLE AND ADDRESS OF CERTIFIER (Type or Print)•
<br />Jane;A. MCDOna.id, MD,. -800.N Alpha Street, Grand Island,. Nebraska, 68803 ..
<br />RE/1t1.j_i
<br />BEENGONSIDERED?
<br />26b. WAS CONSENT GRANTE
<br />Not Applicable N 26a is NO
<br />28b. DATE FILED BY REGISTRAf iffici iyi.
<br />August 24, 2017
<br />
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