|
til tZ�SN�Ii}i%yiG%yssuPr:+Jr)111��
<br />N /irlrri111ip1�cttpU+Pi7�ri
<br />crGt{/Ii1111t1tIs,` rlr
<br />..:lir ;:..t1 •. .rl.... --\d/r rr r .1/ 1 11I. n 1 Ir
<br />.tl. 4I ..t.t 111 11 0 .-.+\ // , .Y 1 Il d 11 / tC. 1 ! Illi rr
<br />1 1. I . / s. 1111/hll ....Ct \I // S 111 1111 . \\ / ,
<br />11 IYI r ,Yt 1 / t , \ d 1 I Y 1 �..-t I/ /,,.
<br />t i ( 111/ , n 1 m, . 11 I / :.. r / . t 1 / .
<br />Y / 1 .. h 1411 h 1 . rer , . t,.,,.11l.,t r .ti nR last. 1 1, , 1 Ill) .n
<br />� ,Nuwr7..e/dW.au.mtt /E2,rr[..1\t... 1. u.. ,u!(A..1... \f r L..r .. , . flows N ulllr4ar!(
<br />.�) (11 111112 fff
<br />i� �rdvhpt» � iirrlTi 111ft`t� jtt.+lei
<br />/Grr/}/,nlll .:rGltlrl.111P1CJDAPt /rNthi't11\ !/ ellf1iI11\ee IInr.InN .��f/la �ttlt,p3.
<br />STATE OF NEBRASKA
<br />!rl rr 1�1�1111 ft `<::::"'"t•11�ir
<br />{drMl}1�11i�tt,> g.
<br />t+HEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE IMTIf THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />IUMAN.SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE:Q I$$UAN. E
<br />5/1;6/202>
<br />LINCOLN, NEBRASKA
<br />. 2.)aRa.rzrkit IAc
<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 />1 .#SiaCEOEf!f7`S NAME :tFfrat, Middle, Last, Suffix)
<br />June Frederiksen
<br />4 DITYANDBTATEORTERRITORY OR FOREIGN COUNTRY OF BIRTH
<br />urora,
<br />ebra
<br />9 SOCIAL eabbarT'> .NUMBER
<br />506 25 9 79
<br />AGE - Last
<br />(Yrs.)
<br />93
<br />8tr. FACILITY -NAME ()f tet Institutf rn,'give
<br />Azria Health Broadwell
<br />9a. RESIDENT
<br />Nebrask
<br />set and number)
<br />WN L3FDittATH (inoluite Zip Code)
<br />nd 68803
<br />,$TATE
<br />9d STR€ETAN.0 NUM64R
<br />680 S SSS ady Bed Road
<br />2. SEX
<br />Female
<br />Birthday Sb. UNDER 1 YEAR Sc. UNDER 1 DAY
<br />MINS.
<br />MOS.
<br />DAYS
<br />8o PLACE OF DEATH
<br />.HOSPITAL [Q Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />lila. MARirAl iTATUS ATTIME OFDEATH ❑ Married ❑ Never Married
<br />w 0 Married, but separated RI Widowed 0 Divorced 0 Unknown
<br />ATHER`$NAME (EIt,''
<br />Inter Eastman
<br />13AfikR tN;E
<br />''(Yes, i416:',o
<br />Suffix)
<br />ARMED FORCER?' Give dates of service if Yes.
<br />1k)No:
<br />18. METHOD OF DISPOSITION
<br />Er
<br />BLlrtal :: (Dotfa#fon
<br />. 3 Crenlatlor't 0Ent0nlbment ..
<br />ftemova) ❑ Other (Specify)
<br />1Ta FUNERA
<br />Alf Faltf
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />OTHER J Nursing
<br />❑`Decedent's Home
<br />+] Other (Specify)
<br />22.06158 22 06158
<br />3Y DATE OF baler l {R1 tray, '.0
<br />April25 2022
<br />8. DATE Of BIRTH {Ma„ Ctsy, Yr.l ..
<br />une 14,.1;
<br />I8d. COUNTY OF DEATH t
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />NAME (7F SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Gerald Dean Frederiksen
<br />12. MOTHER'S -NAME (First,
<br />Mabel West
<br />14a. INFORMANT -NAME
<br />Gary Dean Frederiksen
<br />18a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Giltner Cemetery
<br />JN $IDEOITY:QUITS:
<br />1s ❑.N<.
<br />18b. LICENSE NO.
<br />1397
<br />IQME NAME AMR? MAILING ADDRESS (Street, City or Town, State)
<br />uneral Home. 2929 S. Locust Street, Grand !stand Nebraska
<br />CITY/ TOWN
<br />Giltner
<br />. RE
<br />TIt7NSHIPI TO OEtw NT>
<br />CAUSE OF DEATH (See !Instructions and examples)
<br />18. P`of Enter Em chain of eVants- 4114041n , Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />sE (Plnai a) Cerebral vascular accident
<br />IMIMEDIAT C,At3
<br />Heise or col twn
<br />Itraeetl}1 ,
<br />Sequentially 8etpondhMor
<br />(My, leading to,ttie.cauee list
<br />Et}tgrtba UNDERLYING GAI J
<br />(df8gitae or injtita'that Inittefed
<br />the: events resdking:In death)
<br />LAST
<br />1$ *ART:l1, ?:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Warta( fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />40.0&::?
<br />[EI! SIGNIFICANT CONDITIONS -Conditions contributing te.thedeath but not resulting
<br />the:Underlying cause given in PART I.
<br />2o.'IF t°!MALE -
<br />Q
<br />Choi eegnentwitttln ppb
<br />Pregtmntattidieof dean
<br />Nttipregox(it butpregnent within 411daysoffdeath
<br />❑. Not pregnant, but pregnant 43 days *01 year before death
<br />Ifnknown }fpragnant µ1!t!1}a are pest year
<br />22a ;DATE OatNJURY tM:e•, Day, Yr.)'
<br />21a. MANNER OF DEATH
<br />® Natural 0 Hotpicide
<br />❑ Accident ❑panting lnvestiaa*Mn
<br />0 Suicide ❑Could not be determined
<br />22b. TIME OF INJURY
<br />22d )NJURY ATWORK?
<br />❑ YES O NO
<br />22f t.00ATt(9N;OF (N1it11t;Y STREET& NUMBER, APT.No.
<br />i
<br />0
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Q Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />ofleettodeedt.
<br />19. WAS Ii0E4 #./EXAiW(ER`
<br />OR C09CONTACTED?
<br />❑ NIS', I4o
<br />21d. WAttroPsio AVAI LAIL 6
<br />TO COMPMEMOMUEMOP DEATH?
<br />❑ YES
<br />22c. PLACE OF INJURY -At hernia, farm, street, factory, office building, construction she;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 25, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mary 12, 2022
<br />CITYl
<br />23c. TIME OF DEATH
<br />05:45 PM
<br />0.T The has* of my,. knowledge, death occurred at the time, date and place
<br />*fd slue to theCeuse(et ateted. (Signature and Title)
<br />Travis S. Hageman, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />240.0n the basis of examination and/or investigation, Ming opintart death a4:4
<br />teatime, date and place and due to the cau e(s) stated. Isignatlrra-atld;
<br />28. DID TOBAGGO USE CONTRIBUTE TO THE DEATH?
<br />[(YES (N4 PROBABLY 0 UNKNOWN
<br />2f NAME; TITLEANIf ADDRESS OF CERTIFIER (Type or Print
<br />Travis 5, Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 6880
<br />28a. HAS ORGAN OR TISSU.E DONATION BEEN CONSIDERED?
<br />0 YES El NO
<br />26b, WAS CONSENT . ,?
<br />Not Applicable if Zea is NO) ❑ YE8 J NO'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 12, 2022
<br />
|