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<br />STATE OF NEBRASKA ) '
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES -THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OR 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 GF ISSUAN
<br />7/3/2022
<br />LINCOLN, NEBRASKA
<br />202205664
<br />/ ? t „),44.41IT, ci fdt-
<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 />t L1ECEDENT'$ 4AMl: (First, Middle, Last, Suffix)
<br />Rcnald Dean Emtken
<br />4, C)TY AND STATE (*TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand. Island, Nebraska
<br />7 ,S ILIAL StGURI1
<br />568.01-1989
<br />NUMBER
<br />Sa. AGE - Last Birthday
<br />(Yrs•)
<br />8b. FACILITY -NAME (If not inetitutIon, give street and number)
<br />328 Redwood Road
<br />15b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatient0
<br />DQA
<br />DAYS
<br />HOURS
<br />MINS.
<br />22 08685
<br />3. DATE Of DEATH {Mo. ; Day, Yt:)„
<br />June 20, 2022 .
<br />6, DATE OF BIRTH (Mo , Day, Yr )
<br />May 9, 191$
<br />OTHER 0 Nursing HOMOILTC { 3o p$oefaCUlity
<br />®'; Decedent's ';Home
<br />0 Other (Specify)
<br />113d. COUNTY OF DEATH
<br />Hall
<br />Sc G TY OR TOWN OF DEATH (include Zip Code)
<br />Grtantr island 6803
<br />9a. RESIDENCE -STATE
<br />Nebraska,;: ,
<br />9d STREETANoNuMaER
<br />328 F edarfaod Road
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />fl Married, but separated Q Widowed ❑ Divorced ❑ Unknown
<br />TNEP S4.9 AME (F(rat, Middle,. Last, Suffix)
<br />Edwin Emken
<br />13, EVER IN U.SARMEDFORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk) No
<br />15. M ETHODQF DISPOnatioN
<br />1"'Bur4al I❑DOnaaon.
<br />Cremation:; ❑ sntottibment .,
<br />amovat. fOther(Speclfy)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />as. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />$g+ INSIDE CITY LIMITS
<br />( YES O No
<br />10b. NAME OF SPOUSE (FirBt, Middle, Last, Suffix) If wife, give maiden nate
<br />Trina Smith
<br />14a. INFORMANT-NAMEI
<br />Trina Emken
<br />16a, EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. NtOTHER'SWAME (First,.
<br />Esthtr Howland
<br />1613. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17e,FUNERAL.ROME"NAME AND MAILING ADDRESS (Street, City or Town, State}
<br />All Faiths I=unetat Home, 2929 S. Locust Street, Grand Island. Nebraska'
<br />14b: RELATIONSHIP
<br />Spouse!
<br />16c. DATE {Mor Yr.)
<br />June 22, 2022::.;,:
<br />Nebraska
<br />51001;`:.
<br />CAUSE OF DEATH (See Instructions and examples)
<br />15. PART 1. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibditation without showing the etiology. DO NOT ABBREVIATE. Enter oMy one cause on a line. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATEC,AU¢EiFfnai -i a)Chronic respiratory failure
<br />se or conriatpn relmaing
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ssquemlatly ust;candiddna, if ;:: - b)Chronic obstructive pulmonary -disease
<br />any:leadiita to tlpa cause ibted
<br />Ertei'i he UNt )<Y'ING OAUsE'
<br />(dleeeae ar injury t�at lnhiatan
<br />therevents resuteng ion death)
<br />,... ..,...
<br />APPROXIMATE IN AL
<br />oneet tin death
<br />5 Years
<br />DUE TO, OR AS A; CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />10"57141.0:r.4 R SitPN
<br />'2Q. IF FEMALE
<br />riot pteQtlaat withid haat seer
<br />lre9nant at 1ig18 df death
<br />CI' Not pregnard, buut pregnant Within 42 days of death
<br />❑. Net prsgnaet,'but pregnant 43 days to 1 year before death
<br />❑ Unknown It PreinefftWithInthe past Year,'
<br />22a DATEOF INJURY (Mo
<br />ANT CONDITIONS,Condltions contributing to the deSth but not
<br />he underlying cause given In PART 1.
<br />t='
<br />22d. INJURY AT WORK?
<br />YES NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Imieetigaton
<br />0 Suicide 0 Could not be detemtined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />DoveNoperetor
<br />Passenger
<br />0 pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />i
<br />1
<br />19. WAS MEDrD1J EXAMINER:
<br />OR CORONEiRCONTACTED?
<br />❑ YES j No
<br />21c. WAS AN AUTOPSY.PERFORMED?
<br />❑ YES . Igi BIC.)..;.:::.::
<br />21d. WERE AUTOPSY fiNt'SNGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site; etc. (Spec
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />227LOCATION OF INJURY. -STREET& NUMBER, APT.NO. CITY/TOWN;
<br />23e. DATE OF DEATH ([Mo., Day, Yr.)
<br />June 20, 2022
<br />Tab. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />01:30 PM
<br />y;knowledge,. death occurred at the time, date and place'
<br />;olid eausets) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />25 `DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Yas Nfl ❑PROBABLY 0 UNKNOWN
<br />7. NAME.T1TI4ANADRESSOFCERTIFIER (Type or Print
<br />Ryan D Crouch, DO, 800 N Alpha St, Grand island, Nebraska, 68803
<br />26a. HAS ORGAN OR
<br />❑ YES LaNO
<br />28a. REGISTRAR'S SIGNATURE
<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. On the basin of examination and/or investigation, in my opinion death gOO?(rred at
<br />the time, date and place and due to the causes) stated. (Signature an43ibe)
<br />ATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED
<br />Not Applicable If 26a Is NO LI YE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 27, 2022
<br />
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