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<br />STATE OF NEBRASKA 4((IIti 1�0.k
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TIDE COPY OP THE ORIGINAL RECORD ON FILE WITH ME NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE.O i$SUA.VCE
<br />LINCOLN, ;NEBRASKA,,.
<br />2O22.41.:44.
<br />44. ,84etetzakii,
<br />SARAH BOHNENKAMP I
<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 />DEOEDENT'S'NAME (First, Middle, Last,
<br />Judy Ann Case
<br />4. CITY #ND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand lslard. Nebraska
<br />Suffix)
<br />7. SOCIAL. SEGIJRITt(NtiMBER
<br />507-56 0388
<br />6a. AGE •Last Birthday
<br />(Yrs.)
<br />'S
<br />8b.'FAC1LITY•NAME (jr not institution, give street and number)
<br />23.:16 W. 11:th St
<br />Sc CITY OR TOWN OF DEATH (include Zip Code)
<br />rand Island 688133
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9'a'.`5'fREETaNt�NUMFC
<br />2316W 11th St
<br />105. MARITAL STATUS ATTIME OF'DEATH
<br />0 Married, but separated 0 Widowed.
<br />PAWS. "s NAN/0 (Fleet,
<br /># elbert . Kenvon
<br />75
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a,"PLACE OFDEATH
<br />HOSPITAL t] 1npatient
<br />❑ ER/Ou patient
<br />9b. COUNTY
<br />Hat
<br />Married 0 Never Married
<br />0 Divorced 0 Unknown
<br />Iddle, Last, Suffix)
<br />13, EVER IN U e ARMED FORCES? Give dates ofservice if Yes.
<br />(Yes, No, or Unk.) No
<br />t6. METHOD of DfSPOSITION
<br />❑<BurIel tJ Donation
<br />�. Cremation;: Q Entombment
<br />usual ❑Otlter(Specify)'
<br />9c. CITY OR TOWN
<br />Grand: Island
<br />2. SEX
<br />Female
<br />Sc. UNDER I DAY
<br />HOURS
<br />MINS.
<br />22 05631 ..
<br />3. DATE OF DEAI#I tMO.,,Day YC.},
<br />April 12, 2022
<br />6. DATE OF BIRTH tMo., Day, Yr j
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lob.. NAME OF°SPOUSE (First, Middle, Last, Suffix) If wife, gibe Madden ii
<br />Jerry Case
<br />12. MOTH
<br />Wilma
<br />145. INFORMANT -NAME'
<br />Jerry Case
<br />16a, EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION s
<br />Central Nebraska Cremation Services
<br />175 E :UNERAL;:NOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All: Faiths Ftineral(o'me, 2929 S. Locust Street, Grand Island, :Nebraska ,
<br />'S -NAME (First, Middle,
<br />Belie)
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />INStDE1:t.
<br />�YE$
<br />1413,:RELAtioitiOitab.
<br />Spouse
<br />16c. DATE (Mo ,. Dayt Yr.).
<br />April 13, 2t)2
<br />A
<br />Nebraska
<br />¶7b ZIp'Code
<br />5881
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 6 Enter the chain of events--diaeSSes, Injuries, or complications -that 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 one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a)moderate protein calorie malnutrition
<br />IMMEDIATE CAUSE4Final
<br />dieeaee or condition resulting::
<br />sequentially list conditions, If
<br />:any, leading to ths:taueetistod ".
<br />on linea
<br />Enter.tits UNOEIIGYINQ AuS.E`.
<br />(liiseas* or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />E TO OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease, SIADH, heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />)
<br />d)
<br />18. PARTE OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not res
<br />20. IF,FEMALE , ;:
<br />Hot pregnant ladtma
<br />Preiplam at Bills of d•atn
<br />D;
<br />Not pregnanu,butpregnantwhhin 42 days of death
<br />D Not pregnant, but pregnaitt d3 days to l'year before death
<br />❑ Ualmown n.pregnem within the past year
<br />APPROXIMATE XIMATE INTERVAL
<br />to
<br />onsetCi: ieath
<br />ting in the underlying cause given in PART I.
<br />225 , DATE OF INJURY (Moti Day, Yr
<br />2Ed. AT WORK?
<br />©YES ,❑NO
<br />21a. MANNER OF DEATH
<br />Ei Natural D HontIcide
<br />D Accident D Pending Investigation
<br />0 Suicide- D Could not be determined
<br />22b. TIM E `OF INJURY
<br />21�b»�.IF: TRANSPORTATION INJURY
<br />C{iDriver/Operator
<br />OPassenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER :.
<br />OR CORONERCONTACTEO?
<br />21c. WAS AN AUTOPSY PERFORMED?-
<br />YESNa
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE.
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑NO,
<br />22c. PLAOE OF INJURY:At home„farm, street, factory, office building, construction a
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />LOCATION'OF INJURY:* STREET & NUMBER, APT.NO.
<br />i. DATE OF DEATH (Mo., Day, Yr.)
<br />April 12, 2022
<br />23b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Arli11 13, 2q?2 03:00 AM
<br />23d, Ta to begot my Irnowledge, death occurred at the time, date and place
<br />and: due -MOO faucets) stated. (Signature and Title)
<br />CITY/TOWN::
<br />had Vieth, MD
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />ISSUE DO
<br />STATE
<br />ZIP ODE
<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. Oft Ma 115615 of examination and/or inveetiga ion, in my opinion death oge. nett at
<br />thetidte, date and place and due to the Sause(s) stated. (signature dflF'iae)
<br />ATION BEEN CONSIDERED?
<br />. DID:TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 1: Nfi Cj PROBABLY ® UNKNOWN
<br />27. NA ME,'tIriAmsiD AA..bikass OF CERTIFIER (Type or Print
<br />C) ::Vletll, Mb, 2116 W Faidley #400, Box 9802, Grand Island, • - 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 265 is NO ('.13.4E6
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 20, 2022
<br />
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