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<br />WHEN 7111'S ':COPY CARRIES THE RAISED SEAL OF THE NATE OF NEBRASKA, IT
<br />'CERTIFIES THE DOCUMENT BELOW TO BE' A TRUE COP * OF THE ORIGINAL RECORD,.
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL •
<br />RECO IDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REO DS
<br />DATE OFISSU.AN EE
<br />3/5/2020
<br />LINCOLN, NEBRASKA
<br />.Ceaaraa .avru.al.a�,A,r� r f
<br />Q Z S'68ASSISTANT 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 />20 02606
<br />1 DECEf)ENT'$?NAME (First, Middte, Last, Su
<br />i atrit:k .Henn}s .Iles
<br />)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />spar 'SECURITY NUMBER
<br />400-464647
<br />8a AGE Lest Birthday:
<br />(Yrs.)
<br />78:::..
<br />Sb. PACK -MI -NAME or net institution, give street and number)
<br />. 181.0 W. Louise .. ' .
<br />8c. CtTY OR TOWN OF DEATH (Mdude Zip Code)
<br />Grand Island 68803
<br />9a. RE'SIDENCE STATE
<br />Sb. COUNTY
<br />Hall
<br />Nebraska
<br />STREET ANp NUMBER:
<br />E150/ IJtl'S�
<br />1Oe.`M4 iTAL i TATUS.ATTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1. FATHER'S-i±t. kME [Fkst, Middle, Last, Suffix)
<br />Dale 1�t(II y
<br />13 EWER IN U S ARMED. O•RCES? {five dates of service U Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />: Q Donation
<br />•cromadon; QEntaa mens
<br />Q Ramous, �] (Speci
<br />f
<br />y)
<br />5b..UNOER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa, PLACE O DEATH
<br />HOS ITAL Q liMatler t
<br />0 ER/Outpatient
<br />Q DOA
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />)
<br />HOURS
<br />MINS.
<br />3. DATE OF DEA*
<br />February 22 X20:
<br />5. DATE OP BIRTi' 4filo., Day t
<br />Februatc.lg,1.942
<br />OTHER Q Nursing Homs/4.TC. Q klosp co
<br />® Decedents Home
<br />© Ogler (SpocIN) . .
<br />ed. COUNTY OF DEATH
<br />Hall
<br />APT. NO.
<br />If. ZIP cote
<br />688031:1)-4100m Crop
<br />I4SIDE CITY NMITS
<br />7Ob NAME:OF SPOUSE (First, Middle, Last, Suffix) I wile, give maiden
<br />Dianne Ostdiek
<br />12 M.THEtt SgNAME (First, Middle, Marden Surname)
<br />• Robe to /inQert
<br />14a. INFORMANTN
<br />Dianne Willey
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Capel, 3005 S. Locust St., Grand Island Nebraska
<br />lab. LICENSE NO.
<br />CITYITOWN
<br />Gibbon
<br />CAUSE OF DEAT(Seo iftsttuctlOns:and examples)
<br />13. PART 1. Enter the Winn of events- -diseases, Injuries, or complicanons that dhesty caused the death. DO NOT emir terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • ane. Add additional lana If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAuleiFIneI a) Respiratory Failure
<br />dlosarse or eandk at raatdNnO
<br />14b. RELATIONSHFP,. 4CE
<br />Spouse
<br />1(1c DATE (Ma, Day, Yr.) ,.: <,
<br />February 23, 2020
<br />ebrsska
<br />1?iA : : ,
<br />APPROXIMATE INTERVAL
<br />Onset towpath
<br />2 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Ilst conditions, if b)Squamous Cell Lung Cancer
<br />any, hope to the >came .toted
<br />EitterthetatiOSSURNOMAtISS'
<br />p(diasssa:tr injurythat initlitted
<br />the *Vents neutting in death) : DUE TO;'OR AS A CONSEQUENCE OF:
<br />u+$T. d)
<br />onset to death
<br />27 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset todseth
<br />184pART tl OT1 ER SIGNWFICANT CONDmONS-Condltlone contributing to the death t o
<br />Entf Stage R tat 1 l ease, Atrial Fibrillation, Colon Cancer, Stroke ..
<br />210 Natural MANNER OF DEATH
<br />at*
<br />ome
<br />Accident Q vin chug hwa.tigalian
<br />E3 suicide [l Could net be dntanbid
<br />•i•
<br />O 1F FEMALE
<br />0 NotpntpnesttwithHlpsetyeer ®
<br />Q Prem, atlum of dead, Q
<br />t Not pr griiiiw ut pAgtlsnt within 42 days of d•Mh
<br />,5f 0 Nix pr satin•,. Ddl pregnant'. 43 says to 1 y b fSts death
<br />+stAtTilinlifilialliifpripinityhyrhhin the past year
<br />220 1ATE OF1111URY (Mo iDay 22b. TIM?OF INJURY
<br />22d. INJURY AT WORK?
<br />QYES::QNO
<br />,Yr.).
<br />E the; •redo •
<br />In PART 1.
<br />21b tF. TRANSPORTATION INJURY
<br />b09!/Opantat
<br />I� �r
<br />p:Pedestrian
<br />CI outer meershe
<br />19 iNAS MEt'f3 1; &xAMtNER : is
<br />ORGORONER TACT ?
<br />Q YES &i NO
<br />Rio. WAS AN AUTQPsy stares MEND
<br />I: Q Y66 6th I>fo
<br />2 d.
<br />22c. PI
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CATiON'Oftlf URY STREET & NUMBER, APT.NO.
<br />.............: .....:. ....:.
<br />..... ....... ....... ......
<br />....... ........ .............
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 22, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 22.2020 `
<br />234, Te1ti hast offek tnowledge, death occurred et the time, date and place
<br />Mut dus to the aausets) stated. (signature and title)
<br />Isaac) Berg, MD
<br />tC
<br />F tNJUR'P:At lxtteke firm street, factory, *Mee builditek.cont
<br />STATE
<br />23c. TIME OF DEATH
<br />05:19 AM
<br />240 DATE SIGNED (Mo., Day, Yr.)
<br />24b. TAME Dir DEAT)1
<br />24d. TIME PRONOUNCED DEAD
<br />24e O.nthettesle asxeminadonand/or imaatlgaaon,Inray eptnAMNW1sctt
<br />to t me;'tlete and plan and due tottts auie(sjst.t d (signahn eliEtTN ,) ;;
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />28 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a .HAS ORGAN OR TneSUE DONATION BEEN CONSIDERED?
<br />[ { YI?S 0 Mtn ]PROBABLY UNKNOWN
<br />OYES Q NO
<br />NAME,'.1Tt,S AND ADDRESS OF° CERTI (type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339 'Grandtsland Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CON$MNTGRAN:TED?
<br />Not Apptiosble N 288 ts.NO
<br />28b. DATE FILED BY R1IGISII R
<br />March 3, 2020
<br />Day, Yr.)
<br />
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