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<br />WHEN ` THIS ' COPY . CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, l IT
<br />GERTIPES 7HE 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 RECORDS
<br />DATE OFISSUANCE
<br />2/41202'1
<br />LINCOLN., NEBRASKA
<br />202203$77
<br />0
<br />°w
<br />1
<br />siC
<br />1
<br />3
<br />:of
<br />1 .AECEDENT`$ NAaI(E {Flraf; MMdle,
<br />, ulIe Anrt Splattstoesser
<br />4 Gl3YAN
<br />SARAH BOHNENKAMP
<br />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 />Suffix)
<br />STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />9ilton, Florid
<br />7 $OCJAL SECURITYNUMBER
<br />5O8 13-O429
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Merrick Medical Center
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />50'.
<br />5b: UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 1:3 Inpatient
<br />(0: ER/Outpatient
<br />0 DOA
<br />8c CITY OR TowN OF PE.ATH (Include ZIP Code)
<br />Central City 65826
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d; STREETAND NUMR
<br />1110 Steftar Street
<br />9b. COUNTY
<br />Hall
<br />loo MAINTAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S -NAME (First, : ; MId
<br />William. Clair.. Schlachter
<br />13.:EVER IN U S ARMED; Fi
<br />(Yes, No, or Unk.) No
<br />Last,
<br />ES? Give dat
<br />18. METHOD OF DISPOSITION
<br />O Buttal O Donetfon
<br />ra atnatro i ❑ Entombment
<br />].Removat.l ❑Other(Specity)
<br />sofas
<br />Suffix)
<br />Ice if Yes.
<br />9c. CITY OR. TOWN
<br />Alda
<br />HOURS
<br />MINS.
<br />S. DATE OF PEATNINI04ttayr-)`I
<br />Decerrtber S1, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr)
<br />February 26 .:1970
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ other (sly)
<br />Bd. COUNTY OF DEATH
<br />Merrick
<br />De. APT. NO.
<br />9f. 21P CODE'.
<br />68810
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) 1f wife,,,
<br />Wale Faculty
<br />Kevin Scott Splattstoesser
<br />112. MOTHER'S -NAME (First, Middle,
<br />Gloria Kay Wessman
<br />14a. INFORMANT.NAME
<br />Kevin Scott Splattstoesser
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a FUNERAL'HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />A)f FatthsFunerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />4 r0gtipECI'ryr''1 iNE.1TS'
<br />YES 1,.4 NO
<br />e.
<br />Maiden Sumac
<br />14b REI ATiOft1)HIP TO OEO`EDENT
<br />Spouse
<br />18c. DATE tM.., Day, Yr.)
<br />January T 2021:;:
<br />CAUSE OF DEATH (See instructions and examDlesl
<br />18. PART I. Enter the chain of events- -diseases, Injuries, or complications -Mat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, orventricuter fbrilation. without showing the etiology. DONOT ABBREVIATE. Enter only one cause on. a line. Add additional lines if necessary:
<br />IMMEDIATE CAUSE:
<br />IMMEP FATE CAt1$E (Fina . .
<br />tuarem or aonditwn re*untflp
<br />lode** : :
<br />Sequentially asttonditions, if..
<br />any, leading te:N)e cause:listed
<br />altliria a. .. ..
<br />En$r.tBe.::UNOMMN l(IGCCAUSE
<br />(dfsewa or blurt'. that imfinted
<br />18 PA
<br />U. O
<br />a) Cardiac Arrhythmia
<br />STATE :.
<br />Nebraska
<br />:.4.7&:X111Coale,
<br />6810 k'
<br />APPROXIMATE INTERVAL
<br />onsetto death.
<br />t/104lba
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Mitral Valve Prolapse
<br />DUE To, OR AS A CONSEQUENCE OF:
<br />C)
<br />ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />.20.#F FEMALEr :,
<br />®:. Not proglmid witih&t pesiyaar
<br />Pregnantat-line 01death;
<br />a
<br />Nof Pregnsnl, but pleggnam-victim 42 gays of �aM
<br />❑..,Not Pregnant, but pregnant 43 days to 1 year before death
<br />❑ ;Unknown Mregmattt within itis paef'paar
<br />221u OATS OI::INJURY (Mo,, Pay, Yr.)
<br />22d. INJURY AT WORK?
<br />YES..1 NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending lnvestigatron
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />„❑ Driver/Operator
<br />O Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />18. WAS MEDICAL EAi(QEtt J ?'
<br />QR CORONER CONTAOT.Dt(
<br />YES ❑ NO
<br />tic. MEAN At.rTOPSY P: FQRMEP?
<br />® YES d NO <.
<br />21d. WERE AUTOPSY ANDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />• YES [❑ No
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OP:INJURY STREET &NUMBER APT no
<br />23a. DATE OF DEATH (Mo., Day. Yr.)
<br />December 3i; 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />.ianuare.7.2021
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:57 PM
<br />a#¢e Lest oE:my knowtedgs, death occurred at the time, date and place
<br />aria duo to Me causes) stcted. isign ire and Title)
<br />Robert E. Bowen, MD
<br />25. D)DD TOBA GO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ... fisi NO ❑ PROBABLY 0 UNKNOWN
<br />27' NAME, T IkE APifTfoimESS OF,CERTIFJER (Type or Print
<br />l=•'
<br />fi obert Boweti,, MD, 4840 F St, Omaha, Nebraska, 68117
<br />28a,REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED
<br />a4e.:On the Basis of examination and/or investigation, M my epMknr d5ate lifituree st
<br />tbotirrie, date and place and due to the causes) stated. (BigsaturStifgrfitlej,<
<br />26a. HAS ORGAN. OR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ❑ NO
<br />26b. WAS CONSENTGRI
<br />Not Applicable if 26a Is NO
<br />28b. DATE FILED BY ftEGISTRA
<br />January 10, 2029
<br />NO
<br />, Yr.)
<br />
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