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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 />RECORQS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUAli10E
<br />5128/2021
<br />L INCQLN, NEBRASKA
<br />202203749
<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 />l. DECEDENT`O NAME (First, Middle, Last,
<br />k ichard.: Kittridge
<br />Suffix)
<br />4 CITY AND STATE OR TERRITORY, QR FOREIGN COUNTRY OF BIRTH
<br />Greeley County, Nebraska
<br />7,006AL s uRnvi
<br />606.42-4730
<br />MBER
<br />8b. FACILITY NAME (I# not Institution, give street and number)
<br />1920 W. Oklahoma
<br />80,01TY OR:TOWN OF::DEATH (Include Zip Code)
<br />:Gral'Id Ill id 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9c1, STREET AND NUMBER
<br />4920 W: Ok[ehofrie
<br />5a. AGE -Last: Birthday
<br />(Yrs.)
<br />86.
<br />50, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Q inpatient
<br />❑ER/Outpatient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS ;AT'TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S NAME (First; MI5
<br />John P Ktttrid5)e
<br />Last, Suffix)
<br />13 EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />98 METHOD OF DISPOSmC N
<br />I I C Dtmatlon
<br />I Crematahn cl.400thn.nt
<br />j Removal ! CI Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH..: (ISo„ Day, Yr.)
<br />May 19, 2021.
<br />6. DATE OF. Hi R'Itl (Moi, Day,Yr.)
<br />April 22,:::1936.::;..
<br />OTHER 0 Nursing Home/LTC
<br />® Decedents Home
<br />0 Other(Specly)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Hopicei?tlRtli(ty !;s
<br />9g iN61IllR4(TYktiv TS
<br />i YES ❑ NO.
<br />10b. NAME OF SPOUSE (first, Middle, Last, Suffix) If wife, give maiden name
<br />Martha Jane Kittridge
<br />112. MOTHER'S -NAME (First,"
<br />Mice Stout
<br />14a. INFORMANT -NAME
<br />Martha Jane Kittridge
<br />165. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b, LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examoles)
<br />14b. RELATIONSHIP T6 DECE'r
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.
<br />May 24; 2021
<br />id. PART I. Entertiie chain of events- -diseases, injuries, or compiications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only onecause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAiI$E (Fina, > a) Late Onset Alzheimer's Disease With Behavioral Disturbance
<br />!8#esq tr condltipn resulting;:
<br />fdageth) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially 1st conditions, If b)
<br />any, leading tothe cause listed
<br />online a
<br />>Enter the.Ut DERI VINO C/t 81
<br />(dleege or Iryury:that kdlleted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />17b.2ap Coda
<br />68801:
<br />APPROXIMATE INTERVAL.
<br />oneetto death
<br />8 Years.
<br />tit to doh
<br />1.9 iPART fI O f . EP/SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />Lewy Body Dementia With Behavioral Disturbance, REM Sleep Behavior, Periodic Leg Movement Disorder, Bilateral
<br />Sensorineural Hearing; Loss, Compression Fracture Of T12, Hypothyroidism, Hyperiipidemia, Osteoporosis, Basal Gell
<br />20; IF FEMALE; :-
<br />r�J Notpregnantwteinpasi:Yeer
<br />4J'
<br />Pragea4di nme of deagti
<br />❑:: Not pregpnj t, but iiragnantwithin 42 days of death
<br />,Not pregssnt, but pregnagt 43 days to 2year before death
<br />❑::Unknown if pregnant wl hsi she pati year' f
<br />DATE.0 :;INJURY (Mo:, Day, Yr.)
<br />22d.INJURYAT WORK? ; m
<br />❑ YES ❑ NO
<br />22e. DESC
<br />21a. MANNER OF DEATH
<br />® Natural. 0 Homicide
<br />0 Accident 0 Pendine Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑:Pedestrian
<br />0 Other (specify)
<br />21c.WAS AN AUTOPSY @ERF
<br />El YES
<br />NO
<br />.....................
<br />le. was mm04 ExAMltrtue' ';:t i.
<br />OR CORONER CONTAC't'&b?:'
<br />❑ YES NO
<br />21d. WERE AUTOPSY :61910IN/3SAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />YES NO
<br />22a
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction >00 Imo)
<br />HOW INJURY OCCURRED
<br />229<LOCATION INJURY STREET 8: NUMBER, APT.NO.
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />May 19, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />. May 19;::2021
<br />CITY/TOYUN
<br />23c. TIME OF DEATH
<br />03:08 AM
<br />Toth* beat of mXenv/Wedge, death, occurred at the time, date and place
<br />aad due t9 the cauae(a) stated. (Signature and Tale)
<br />Kimberly A. Mickels, MD
<br />28 DIp TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />;0 YES, ENO } PROSAELY ❑ UNKNOWN
<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 DEAD
<br />24e• pn the basis of examination and/orinvestl9eton, It:my opinlon deatit adtntneti X
<br />.the ti(Xie, date and place and due to the eau els) stated. (sigiwture tied Tab)'::
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES l23 NO
<br />27. >.NAME r TITLE AND ESS OF CERTIFIER (Type or Print
<br />Kirriber)y:A. Midke s, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?....
<br />Not Applicable if 26a Is NO S I YES;,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,
<br />May 25, 2021
<br />d
<br />
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