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<br />STATE OF NEBRASKA
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<br />,11 �(rIl'I"� III
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OPNgsfosickirpEpTIFIss THE DOCUMENT BELOW TO
<br />BEA TRUE COPYOF 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 />Ara Ol:'.1SSUANOE
<br />9/6/2022
<br />LINCOLN NEBRASKA
<br />SARAH BOHNENKAMP;
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />:2
<br /># e
<br />U
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 DMCEDENT'S'NAME {First, Middle, Last, Suffix)
<br />Ltslle ROuee 'Sr
<br />CERTIFICATE OF DEATH \"
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Osbome,-'Kansas;::;..
<br />i SOCIALSECURITY NUMBER
<br />480-.59-8568
<br />(lb. FACILITY -NAME (If not institution, give street and number)
<br />Azrla Health Broadwell
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska `.
<br />tad. STREET AN© NUMBER:;
<br />2608 Lamar,Ave ,
<br />toe. MARITA#
<br />0 Meme
<br />SAT TIME OF DEATH
<br />operated 0 Widowed
<br />Bb. COUNTY
<br />Hall
<br />5a.:AGE - Last Birthday'
<br />(Yrs.)
<br />78
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0lnpatieet
<br />• �] ER/Outpatient
<br />❑, DOA
<br />Married 0 Never Married
<br />]"Divorced 0 Unknown
<br />11. FATHERS (SME (Fir'st,
<br />Raymrnd Roue
<br />13. EVER IN U.S. ARMEO'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />11 METHOD OF DISPOSITION
<br />[;.Burial :Donation
<br />( CrematOri D Entombment
<br />Removal QHier (Specify)
<br />Middle,
<br />Last,
<br />Suffix)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />16b NAME OF SPOUSE (First,
<br />Marie Streeter
<br />14a. INFORMANT -NAME
<br />Marie Rouse
<br />16a. EMBALMER -SIGNATURE
<br />Chandler N Yurk
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />VUastlawn Memorial Park Crematory
<br />HOURS
<br />MINS.
<br />221
<br />3. DATE OF DEATH (inti., Da)R
<br />August 23,:2622'
<br />6. DATE OF BIRTH (Ma,Day, Yrs)
<br />October 1S,;1943.
<br />38
<br />OTHER ® Nursing Home/LTC © Hospice Faowty
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Middle, Last, Suffix) If wife, give maiden name
<br />tiaji$4.0l0eStTYt1 rrs.
<br />YES ORO
<br />12. MOTHER'S.NAME (First, Middle,
<br />Lelah Hammond
<br />1eb. LICENSE NO.
<br />1565
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS(Street, City or Town, State)
<br />Litiingstbn.4onderrnann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />alden'Surname)
<br />14b. RELATIONSHIP TO DEEEDENT
<br />Spouse
<br />16c. DATE (Mo..Day Yr.)
<br />August 30, 2022
<br />15. PART L 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 fibrillation without showing the edology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />INN DlATSCAtatdli`rast a)Chronic Obstructive Pulmonary Disease
<br />dis am° or wow
<br />in death)
<br />Sequentially list conditions, If
<br />t� . elm. IQadiug. to tix pause fEstad
<br />Q on IIIF4 a.
<br />w EnteryheWIDE.I3YINt:t;AUSE'
<br />p` (dlseaae Ot injuryitlat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS ACONSEQUENCE OF:
<br />b) LUNG CANCER
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)TOBACCO USE DISORDER
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Nebrasi
<br />17b. Zip C
<br />803
<br />APPROXIMATE INTERVAL'
<br />SPhstt aeattt:.
<br />>10 Years . •
<br />onset to death
<br />>5 Years
<br />onset /041411.
<br />>30 YEAS
<br />onset to death
<br />II OTHER
<br />Ali
<br />f ICANT CONDITIONS -Conditions contributing to the death but not resit
<br />'B
<br />& ai
<br />rro
<br />0
<br />a.
<br />24. IF.FEMALE...
<br />Not pregnant:waM» Paat veer _
<br />Pregnant at time of dean '
<br />D;,
<br />0 NOt pregnant; but pregnant within 42 days of death
<br />❑ Not pregnant,:But pregnant 43 days to 1 year before death
<br />(3almown irpisgnsrd Within the peat year
<br />22a :'DATE taF:ifV,1URY (Mo.! Day, Yr.)
<br />22d. INJURY AT WORK?
<br />©YES IDNO
<br />21a. MANNER OF DEATH
<br />® Natural D Homicide
<br />D Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />e underlying cause given In PART I
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21b.IF TRANSPORTATION INJURY
<br />Q Ortyer/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICALEXAMMER.
<br />OR CORONER CONTACTED/
<br />❑ YES fi} NO
<br />21c. WAS AN AUTOPSY PEREORME
<br />YES, ®MO
<br />21d. WERE AUTOPSY FINDINGS AVAtkASte
<br />TO COMPLETE CAUSE OF DEATN?
<br />0 YES ' ❑ NO
<br />URY At home, farm, street, factory, office building, construction site, etc,: (
<br />22f. LOCATION OF INJURY«STREET & NUMBER, APT.NO.
<br />s
<br />23a. DATE OF DEATH (Mo, Day, Yr.)
<br />August 23, 2022
<br />CITY/TOWN:
<br />33b DATE SIGNED (Mo., Day, Yr.) 23c. TME OF DEATH
<br />Alroti t29<022 063 PQ M
<br />23d Tethe haat of to knowledge, death occurred at the time, date and place
<br />a it duel.IPS c'euse(s) stated. (Signature and Title)
<br />Kenneth Vette!, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24
<br />TIME PRO
<br />ZIP
<br />UNCED DI
<br />24e. On the basis of examination and/or investigation, In opinion death osguriSd at
<br />the tiate, date and place and due to the cause(s) stated. (Signature 100 7.01e)
<br />ie)
<br />2$. DID T08AGG0 USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR r • TION BEEN CONSIDERED?
<br />❑YES
<br />YES' NOVPROBABLY ❑UNKNOWN 1J
<br />27. NAME, Tlf(. ANOADbRESS OF CERTIFIER (Type or Print
<br />Kenneth etteC,1UCD, 2116 W Faldiey #400, Box 9802, Grand Island, Nebraska, 68803
<br />®L!
<br />28a, REGISTRAR
<br />SIGNATURE
<br />E
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO YES
<br />28b. DATE FiLED BY REGISTRAR (Mo.,,
<br />August 31, 2022
<br />
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