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<br />STATE OF NEBRASKA
<br />5rryaty
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<br />WHEN THIS COJ CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE AE TRUE DOPY" 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 />111/2022
<br />LINCOLN, NEBRASKA
<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 />22 06121
<br />t1. DECEDENV$IAME (First, Middle, Last, Suffix)
<br />Alta Etta EtUce
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Eureka, Kansas
<br />5a. AGE Last Esthday
<br />(Yrs )
<br />83
<br />b.
<br />DER 1 YEAR
<br />2. SEX
<br />Female
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />.HOURS
<br />MINS-
<br />3. DATE OF DEATti
<br />May 1,2022
<br />8. DATE OF B RTH.(;Mo., Day,.Yf4
<br />November .x.,1938
<br />8t)C1AL $ECUIt1TY NUMBER
<br />510 344329
<br />FACILITY•NAME1Knot Institution, give street and number)
<br />3123 Laramie Drive
<br />Sc. C['kY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island S8a 3
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER;:::
<br />3123 Laramie Drive
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC Hesptce Fat
<br />0 ERJOutpatient E Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />0110TrAL STAT71S AT TIME OF;DEATH ® Married ❑ Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S NAME (Fust, Middle, Leat, Suffix)
<br />Earl J Walford
<br />ERIN FORCE,
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF. DISPOSITION
<br />� auHai ©Deiita#Ion
<br />❑iCrematied; QEntombment
<br />❑ Removal { Other (Specity).'
<br />es of service It Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />1t)b' NAME OF. SPOUSE (drat, Middle,
<br />Roger Bruce
<br />Las
<br />9f. ZIP CODE
<br />68803
<br />Suffix) if wife, give maiden
<br />112. MOTHER'S -NAME (First, Middle, Maiden Suimeme)
<br />Dorothy Mc Combs
<br />14a. INFORMANT -NAME!
<br />Roger Bruce
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />18d. CEMETERY, CREMATORY OR OTH!
<br />Grand island City Cemetery
<br />LOOMION
<br />la. FUNERAL HOME:NAM. E AND MAILING ADDRESS (Street, City or Town, $tats);,.
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1448
<br />CITY / TOWN
<br />Grand Island
<br />A E OF a �' ' i -se. natru nes and examDle:a)
<br />9g:)NSE gl'fLHIIIT$`,
<br />( YES Q. NO
<br />14b. RELATtONSI!IIIp TO
<br />Spouse
<br />16c. DATE (Mu y Yr.)
<br />May 6, 2022
<br />TATE
<br />Nebraska.
<br />11b, ZIP: Gods:::
<br />68801
<br />ART I. Enter theohain of events- diseases, !Murree, or compticadons.that directly caused the death. DO NOT enter terminal events such as cardiac west,
<br />respiratory arrett, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 9 necesa
<br />IMMEDIATE CAUSE:
<br />IMMEtxATEOAUBE (Feat a) Squamous Cell Carcinoma of the Lung
<br />disease or condition regaaing
<br />i !Nate)...DUE TO OR AS A CONSEQUENCE OF:
<br />sequentiaity est conditions, x b)
<br />any, Ieading tothe:causslisted .....
<br />line
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enterths UNDERLYING CAUSE C)
<br />(disease dr iniu(yi}lat Mid" :..
<br />>.uriiaatb)
<br />ma events resu
<br />LAST
<br />APPRomMATEINTERVAL`"
<br />onset t0lteath
<br />15 Months.
<br />tach
<br />DUE TO,^; OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to+
<br />tth
<br />18 :PART ti. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death b
<br />Chronic ObStructive.Pulmonary Disease
<br />not: resulting in the underlying cause given in PART I.
<br />19. WAS :MEDt0Ai.,EXAlaNER
<br />OR CORONEROONTACTOPT.•
<br />❑YES` ®NO
<br />tg. IF FEMALE:.
<br />Et 0 NotprBynegteehinpastyear
<br />' ❑ Pregnadt a. tem or deatt
<br />❑ Mot pregnant, bot ottoman waNn 42 days or death
<br />pregnant, but pregnant 43 days tc'1`year before death
<br />❑ Unknown if pregnant wletln the past year
<br />t2a DATE OF INJURY (MO., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident 0 Pending imeptiga ipn
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 OdveWOperetor
<br />Qpassenger
<br />❑ Padestnan
<br />Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />214. WERE FtNi71Nt3S AVAILAsa
<br />AUTOPSY
<br />TO COMPLETE, AUSE OF DEATIi?
<br />❑YES dNO
<br />22c. PLACE, OF INJURY,At home, farm, street, factory, office building, construction eIte,,eeo. (Ept)
<br />220, DESCRIBE HOW INJURY OCCURRED
<br />224. )NJURY AT WORK?
<br />. YES :QNO
<br />„24.7r 22f LFCATtONOF INJURY:.STREET & NUMBER, APT.NO.
<br />`ani
<br />23a. DATE OFDEATH (Mo., Day, Yr.)
<br />May :1.2022
<br />cITYJTOWN
<br />STATE
<br />P CODE
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Mev 2(202? Unknown
<br />nes To t e best Of my tmowledge, death occurred at the time, date and place
<br />adddbe td the reuse(s) stated. (Signature and Tide);
<br />Richard'Fruehlinp, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME Of
<br />TH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examimtlon sndfor investigation, In my apinloa death oca inred at .:
<br />: the tkne date and place and due to the cause(s) stated. (S and ale► '
<br />28a. HAS ORGAN OR TisSA'iiAATIO BEEN CONSIDERED?
<br />0 YES ENO
<br />28. DID TOBACCQ USE CONTRIBUTE'TO THE DEATH?
<br />YES Q Np Q PROBABLY 0 UNKNOWN
<br />h4,4ME, T(TLEiANJD AD0RES8 OF CERTIFIER (Type or Print '
<br />Rlcttard Fruehiing, MD, 2116 W Faidley #400, Box 9802, Grand Island,'Nebraska 68803
<br />28a. REG)STRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO . El TSB
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 4, 2022
<br />
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