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<br />Otteraaaatt t,tsaffiIfIffiemaS .191.1 Nllt I s
<br />HEN THIS COPY CARRIES THE'RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGIN.ALRECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN'SERVIC'ES,IIITAL RECORDS. OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS ' '
<br />DATE OF IS ANC
<br />9/8/2022.
<br />1INCOLN IUEBRAS.
<br />t DECUbENrS NAME #Pi
<br />David tl'llatlace..
<br />4. Gi1'Y AND STATE
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTI1A1
<br />DEPARTMENT OF HEALTH.
<br />AND HUMAN SERVIC
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Middle,. Last, Suffix)
<br />acke:::
<br />CERTIFICATE OF DEATH
<br />TERRITORY, Oil FbREiGN COUNTRY OF BIRTH
<br />lelh'i,
<br />Ian
<br />SOGIALSEOUBIT1r NUMBER
<br />307464868
<br />812. FACILITY NAIy1E'I)fi
<br />ive street and number)
<br />5a, AGE • Last Birthday
<br />(Yrs.)
<br />73:
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />8a, PLAGE OF DEATH
<br />HOSPITAL ❑ Intiattant
<br />two. patient
<br />DAYS
<br />0 DOA
<br />0:4110000 6$Q3<
<br />a RESIDE8(CE4TATE
<br />Nebraska {
<br />d.. T.REETAN POBEk:::.:
<br />3024.Lee Street
<br />Incluile;ZIp Code)
<br />9b. COUNTY
<br />Hall
<br />OF DEATH ]:Married 0 Never Married
<br />idowed. ® Divorced ❑ Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3..DATEOF DEA1
<br />November.
<br />OTHER 0 Nureing.HomeALTC
<br />® Decedent's Home:.
<br />0 Other(Speci
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9.e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1Qi7 NAME OF. SPOUSE (First,' Middle, Last, Suffix) If wife, gh
<br />13 SUER i
<br />:'MET
<br />ARM aD FORCES? Give dates of service if Yes.
<br />s 09129/1986 9 0/07/1970
<br />i00O Disl�ts(T r(
<br />(4.0:;:•:•40por?atlori <°
<br />Entombtr
<br />Otber;(Spool
<br />12.:MOTHER'SKNAME (First, Middle,
<br />Beatrice Isabel Hannon
<br />14a. IN FORMANT•NAME:
<br />Christina Hammeren
<br />'lie: EMBALMER -SIGNATURE
<br />Not Embalmed
<br />,18d::CEMETERY; CREMATORY OR OT+tea LOCATION;'
<br />Central Nebraska Cremation Services
<br />a. FUNERAL'MOME NOME AND.MAILING ADDRESS (Street, City or Town,, State)
<br />So(t iNapn r Fera Home;•1507::77th Street, Central City Nebraska"
<br />CAUSE OF DEATH!IS
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />•i:neteuC;f jrti tnd examples)
<br />..
<br />14b RELATIO SHIP:TOUEOEO;
<br />Daughter
<br />14. PART i Entertea chain ef.avents -tlieeaaee :injuries, or complications -that directly caused the death. DO NOT anter terminal events such as cardiac arrest,
<br />...Writer* firrestArveg'trlfialet flhditetign wjthoia shower* the ettotogy. DO NOT ABBREVIATE. Enter only one cause on a One. Add addhionai lines x necessary.
<br />• IMMEDIATE CAUSE:
<br />):Chron(c Obstructive Pulmonary Disease
<br />A19E CAU&it
<br />erceittlition reed!!!!)
<br />uent Tally: list conditions,
<br />treading t3t(ie. cause listed
<br />TO, OR AS A CONSEQUENCE OF:
<br />hronic:.Tobacco Abuse
<br />TO OR AS ACONSEQUENCE OF:
<br />fdis9a#e>g9rtiai
<br />theevatne resul
<br />:LAST 7.:
<br />SART it OTtIER Stla 1IPICANTCONDIT(ONS.,Conditions contributing to the death bignot resulting in the gitderlying cause given In PART 1:
<br />t9 WAS MEDIOaI L:EXAM14ER:
<br />•
<br />42.daya of death : . .
<br />to 1 year before death'
<br />LOCATION 4F IN4U'
<br />21a. MANNER Of DEATH
<br />I_.k
<br />Natural Homlclda
<br />❑ Accident ❑ Pending htuatitigetltla
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />210, IF TRANSPORTATION INJURY
<br />Q Driv,OY/Operator
<br />Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE:OF !MARTA" home, farm, Street, factory, office building, cons
<br />229, DESCRIBE HOW INJURY OCCURRED
<br />t3TREST8,'NUMBER, APT.NO.
<br />t. Dia TE.OF t EATN (INq„ bay, Yr.}
<br />:NOVBITI e"r. 9, 2 ,18.:•
<br />3b. DATE SIGNED ,(Mo., Day, Yr.)
<br />D errtberl,
<br />2018
<br />Soo
<br />CITYP OWN
<br />23c. TIME OF DEATH
<br />08:34 AM
<br />OfMY.Itneydefige, death occurred at the time, date and place
<br />flu»1s) stated. (Signature and Tide)
<br />O USE: CONTRIBUTE TO THE DEATH?
<br />NQ i+ROBABL.Y'':❑ UNKNOWN
<br />'STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo„ Day, Yr.)
<br />24b. TIM
<br />0
<br />24d. TIME PRONOUNCED
<br />24e. Qntha...gals of examination and/or investlgetton,.In i ty optniet't
<br />thetins;:date and piece and due to the ceuse(s) stated. (s at
<br />TO 28a, HAS OR..GAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YE$
<br />0 YES I NO
<br />2NAM TITLE A11D ADDRESS OfitEk1IFIER (Type or Print
<br />Atian Brt ax f , 444 V Faidley Avenue, Grand Island, Nebraska, 68803
<br />28: DID
<br />SACC
<br />288. REGISTRAR'S' SIGNATURE'
<br />288. WAS CONSENT:0
<br />Not Applicable if 28a ie'R
<br />D.
<br />28b. DATE FILED BY REG)STRAR .,
<br />December 4, 209 $ .. i .....
<br />
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