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EEiggriAdp10(ei3.__11llIIiSd:vAiQMraifueieiIk1tm1�s n_._ntiO nl. 5OUlt <br />wdAI /f <br />STATE OF NEBRASKA <br />,hhh4Ntt, a i�gQl7lAl�tllft.°� /h4ri'PrRuW - z illyA114i11W��e. ,rrniri'i'patAt . <br />Ozoom�i)ii)111ri{iyki �ti+(y1?rVAA' <br />I+i� `rtCitrfflii)iii Irr NIN `t,y�yyyyyyty <br />EN THl$ COPY CARR! THE RAISED SEAL OF STATE OF NEBRASKA, IT CER rFIES THE DOCUMENT BELOW: <br />BE A TRETE CQPY,OF THE OPIGINAL RECORD ON FILE WITH THE; NEBRASKA DEPARTMENT OF HEALTH AND <br />hiUIVIAN'SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />BATE QF't$$UANCE< <br />LINCOLN, NEBRASKA <br />2022.®7 <br />8 <br />YMCA 6Alitiel <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 />EN s• <br />Anel8 An <br />At <br />Suffix) <br />STAT <br />ORTERRITORY, OR;POREIGN COUNTRY OF BIRTH <br />rand tslarid, Nebraska ' <br />OCTAL sECuRITY r1UMBSR- :. <br />dei0e52:27.0. <br />FA <br />1.4:7 5ti Util C3uenther Ro <br />ORT i <br />5a. AGE::. Last Birt)day 5 <br />(Yrs.) <br />53 <br />b uNDER'1 YEAR <br />2. SEX <br />Female <br />5c. UNDER 1 DAY <br />3: DATE Ol: DEATW <br />June 2, 2020. <br />6. DATED <br />MOS. <br />DAYS <br />HOURS: <br />MINS. <br />8a PLACE OF DEATiI <br />HOSPITAL ❑ inpoent <br />❑ ER/Outpatient <br />El DOA. <br />(inc)ude.Zip Cod <br />fotd:.;F trer1 <br />RESIDENCE -STA <br />vl raaka' <br />Auqu; <br />OTHER 0 Nursing Horne/LTC <br />Decedent's Hor <br />0 Other (Specs <br />8d. COUNTY OF DEATH <br />Hall <br />1 <br />9c. CITY OR TOWN <br />Wood River <br />S R.EeTAN17NUM4ER <br />14550 W Guenther Roa <br />II. APT. NO. <br />o.MARiTAL. STATUS ATTyEIE o1:OEATH®.Married 0 Never Married <br />Married but separated: ❑Widoa{ed ❑'Divorced 0 Unknown <br />ates of service If Yes. <br />10b. NAME OP SPOUSE (Firs <br />Kevin Gill <br />12MOT <br />Jane <br />14a. INFORMANT NAME <br />Kevin Gill <br />Middle, La <br />9f. ZIP CODE <br />68883 <br />INSIDE CITY 04)114 <br />❑ ?VsNQ <br />Suffix) If wife, give <br />ERS NAME (First, Middle, Maiden Su <br />auart <br />.:1;!•!•§,F0;01.17.1.90 <br />Datauk. <br />m. Q Entombmen <br />iJther (Spee <br />18d.-CEMEtERY, CREMATORY OR OTHER:; LOCATION::' <br />Wood River Cemetery <br />17a FUNERAL Etl E NAM$.AND MA UNG ADDRESS (Street, City or Town, $tate) <br />Abfel Funeral Home 112311V::2nd; Grand Island, Nebraska <br />$. PARI` 1. Siker tha.clielfl ef:e <br />CITY / TOWN <br />Wood River <br />eases'rtnjuries,or complications4het directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />uet#ric fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a ane. Add additions' tines if noes <br />:1MME0IA1t CAUSE: <br />IA?ECAtisEffnad a)G11ob1aStop,a. <br />tor' eatuNtiorrresu .. . <br />ttl . <br />ttlally oondttlot <br />idilog::t0. the c5..USe <br />!(ip.UNDERl:StIN6-0.C.W. 4 <br />s6' of 1i5)ury-ttriltiiiitbited <br />'encs•resuhingln`deattl>:: <br />NDITIONS-Conditions contributing to the death but not resu)tii <br />hi n 42 daya;ot death' ` <br />daya.to:t yr; before.death <br />21a. MANNER OF DEATH <br />® mnlcNatural ❑ Hide <br />Accident ❑ Pending:investigatiop <br />❑, Suicide 0 Could not be determined <br />riying cause given in PART I. <br />1Tb. tF TRANSPORTATION INJURY 21c. WAS AN AUT <br />�, brhreripperator <br />.QRassenger •CIYES <br />. <br />0 Pedestrian <br />0 Other(Specify) <br />214 WERE'AUTOPSY;PI9 <br />TO COMPLETE CHUB <br />22b. TIME OF INJURY <br />22c. PLACE'OF INJURY -A <br />2e. DESCRIBE HOW INJURY OCCURRED <br />artt3, street, factory, office building, cons <br />TiLlid 0 iNJU <br />3a.•DATE OF DEATH (Mo., Day, Yr•) <br />tlane <br />23b. DAt SIGNED,(Mo., <br />JIrie6 202.13; <br />23c. TIME OF DEATH <br />09:57 AM <br />sedge; death occurred at the time, date and. place <br />gtated:(Signature and Title) <br />28.0ib'i0BACCQUSE CONTtiIBUTE TO2HE DEATH? <br />YES ;NON.❑'PROBABLY ❑ UNKNOWN ❑ YES <br />2T NAME TITLE ANIS ADD1ips OF CERTIFIER (Type or Print <br />Ryan Rarnaekers, Ntp 211.fi W. Faidley Avenue, Grand Island, Nebraska' 688 <br />STATE <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. -!TIME OF DEAT <br />24c. PRONOUNCED DEAD (Mo., Day, Yr. <br />24d. TiME'PRONOU <br />240.On the basisof examination and/or investigation; in oiy opht <br />thedima, date and place and due to the camels) etated..{Sig• <br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />26b. WAS CONSENT GI <br />Not Applicable if 28a to N <br />28b. DATE FILED BY RE <br />June 11, 2021` <br />