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ay.4 1'3h1#9$0Lrr1(r,,,I) i(iilliiirSsin., Aldig 111111/driG0tii rzlaAil)11I' x6,. Att. issio Al(Nrih artils1)iE1i(S)10,.
<br />�� STATE OF NEBRASKA
<br />!htatr.m:6;; 4.untllllinoks !Ay,,,Arttmv r,ff4191fWtto" - r,rrrrn,
<br />rt1NEN 11S COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW Ti
<br />BEA TRUE COPY OP 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 />f1ATE O.E ISSUANt
<br />2t�f202�
<br />INCOLN;-NEBRAS
<br />SARAH BOHNENKAM'P i{
<br />ASSISTANT STATE REGISTRAI
<br />'202206'445 DEPARTMENT OF HEALTH •*
<br />AND HUMAN SERVICES
<br />4TATP OF_NS61RASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEtii NTS?NAME (Fttat Middte, : .'Last,: Suffix).
<br />Terry Otenn
<br />4; CITYANb STATE OR TERRITORY, (R;FOREIGN COUNTRY OF BIRTH
<br />UipsbUra,.:Kansas:
<br />T 800.IAt, $EOURITY NUWBER'
<br />6 6 66x6932
<br />8b, FAOI
<br />TY -NAME {tf not IneU
<br />C HI: t�lealih' .SL .Franc
<br />Ion, give street and number)
<br />8c OfTY OR.TI N OF I EATfi (include Zip Code)
<br />Grand 1SIentt 08803
<br />9a..RES}DENCE-STA
<br />Nebraska`
<br />E t. BtREET AND NUM 9BR:; :
<br />3112 Commanche Awen
<br />9b. COUNTY
<br />Hall
<br />IME; OF, PATH ® Married 0 Never Married
<br />Widowed ❑ Divorced 0 Unknown
<br />11 > ATffER'S;NAND (First, Middle; East; ' Suffix)
<br />bonnie hl►ulr
<br />13.R #N U S ARMED;FORCES? `.Give dates of service If Yes.
<br />15 METH900r.OftWoslr10N:
<br />Bursa{ dunatn •
<br />.r00400.04:31.!.!01,4. nto
<br />Q`FteiaiOvtrt:i 'QOI1s�Fffir)
<br />5a :'AGE - Last Birthday
<br />(Yrs.)
<br />8b.<UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />HOSPUTAL .] Inpatient
<br />ERIOu patient
<br />0 DOA
<br />1Ob. NAME'OF SPOUSE (First;' Middle, Last, Suffix) If wife, give
<br />Rita Havel
<br />9c. CITY OR TOWN.
<br />Grana Island
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS:
<br />MINS.
<br />3. DATE.OP DE1kTtf (Mq:,. Ri
<br />December 255, . O2
<br />OTHER 0 Nutstng:H,
<br />Decedent's Home
<br />❑ Other (Specs
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1. t C)'fi'tf'04fTS
<br />fes :.(,:.Na
<br />14a. INFORMANT -NAME
<br />Rita Muir
<br />Sa. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />12 MOTIHERS;N.AME (First, Middle, Maid.
<br />Gertrude Fisher
<br />16d. CEMETERY, CREMATORY OR OTHER LOOATtON
<br />16b. LICENSE NO.
<br />1537
<br />CITY i TOWN
<br />MB Affb (Street, City or Toxin, tats
<br />1 Funet'al l ome ,1123'W: 2nd, Grand Island. Nebraska.
<br />ART1. Ent
<br />P
<br />CAUSE OF DEATH' ISee: ihattudlont and examples) •
<br />14b, RELATIC
<br />*Wife.;... .
<br />'tap TOW
<br />the chain' ofevents- .diseaties,,inJudes, or complications.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />;,or.ventriwlai' fibralatIon,without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if neves
<br />.r`
<br />IMMEDIATE CAUSE:
<br />V Pulseless electrical activity
<br />EDIATiE DAusEr(Fina(
<br />::::.n .tio . nt„
<br />ease' o;eoitdittorz r•
<br />esuig„,
<br />!ODE' TO; OR As A CONSEQUENCE OF:
<br />emwllytiat�;romugans tt''. b)rfjyoci rditis:
<br />any, fading to the:cairaotisted
<br />tibrttwg<uso
<br />(diaebtleCt inju
<br />PPE TO; OR AS A.CONSEQUENCE OF:
<br />18•PART If OTHER $IPISFICANTCONDITIONS-Conditions contributing to the death
<br />diat'etes type 2 hypertension, Tlyperlpidemia, obesity, hypothyroidism
<br />0. W FEMALEii : ,:
<br />Petd Pie9clatlS W
<br />!Yegrhtlfht at ttfp(r Of r(sadt
<br />, i -ill but rifer tfin }x t 4;400 of death
<br />NOS eregnant jut pregnant 48 Ways to 1�.year.ltefare death
<br />wq it pyegn8e11>HithIn MO pest year
<br />21a. MANNER OF.DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ heading InveEstigatio>r
<br />0 Suicide 0 co
<br />not be determined
<br />not; resulting in the
<br />22b. TIME OF INJURY
<br />DRY STREET:&NUMBER, APT.NO.
<br />OF DEATN.(Mo.,Day,-Yr.)
<br />mber25:2021
<br />22c. PLACE OF 1
<br />CITYITOWN:::
<br />23b,15i 1'E SIGNED (Mo ,.D'eiy„Yr.) 23c. TIME OF DEATH
<br />Fetrri/at�f.3 2022 10:19 AM
<br />Ta:ttnr baatilf ary: Rdovdedge..death occurred at the time, date and place
<br />*1100115113 the.oaus,(s1:etated lstgnature and. Tile) ...
<br />avG Anderson, MD
<br />DIL1 TOBACCO USE:C.QNTR113UTE tO THE DEATH?
<br />YE.SNCI ❑ P#ROBABt Y.' ❑ UNKNOWN
<br />? NAME T#TLEAND ADDRESS OF CERTIFIER (Type or Print
<br />• ..Jey C Anderson, `IVID, 7'29 North Custer Avenue, :Grand Island, Nebraska, 68803
<br />00 40 hi
<br />derlying cause given In PART 1.
<br />2100F. TRANSPORTATION INJURY
<br />a Dritiar/Operetor
<br />Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />,:fatm,:Street, factory,
<br />21d. WERE AUTOPSY.
<br />TO.COMP .ETEp U
<br />building, c
<br />STATE.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OP DE
<br />24d(TIME ppiorptjt
<br />246: Ott the ttaAta of examination andlor Investigation, hi ray ops
<br />the thntO date and place and due to the cause(e) stnted,18
<br />Ip. trOTIE:
<br />0D
<br />p,..
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES J NO
<br />28c..REGISTRAR'S SIGNATURE
<br />26b. WAS CONS'S
<br />Not Applicable' if 26e is
<br />28b. DATE FILED BY REGIS'
<br />February .3, 2022
<br />
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