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<br />STATE OF NEBRASKA
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<br />WHEN mis COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASK!, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRIJE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICE, VITAL; RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OP ISSUANCE
<br />0/30/2022
<br />NCOLN,, NEBRASKA
<br />1. DECEi1EN'E"S-NAME (fret, Middle,
<br />ndrew+ 'Milton Enevold:en
<br />202207 33
<br />Sitit
<br />za
<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 />Last, Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dannebrog, Nebraska
<br />AL:
<br />r $�
<br />cUrtiTY NUMBER
<br />21,
<br />8b. FACILITY -NAME (If not Meditation, give street and number)
<br />CHI Health St Francis
<br />Sc CITY OR Ti5WN OF OEtATH (Include ZIp Code)
<br />Grand IBiatfd 66903:
<br />REstDENcE-STAT
<br />Nebraska.,;
<br />9b, COUNTY
<br />Hall
<br />Ba. AGE - Last airthday
<br />(Yrs.)
<br />80
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER I DAY
<br />MOS.
<br />DAYS
<br />8a: PLACE OF DEATH
<br />HOSPITAL.17,0
<br />0 ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 13080
<br />3. DATE OF DEAirtf (Ma., tiajr'
<br />Septembers 1.2.:202
<br />6. DATE OP BIRTf . Mo.,
<br />August 3:494g............
<br />OTHER 0 Nursing Home/LTC Q I@aspIcePagii
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />I
<br />9dkE'rREST. AND NUh1BF i
<br />4812 Derr ' Dr
<br />10a. MARITAL `STATUEAT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated gl Widowed [] Divorced ❑ Unknown
<br />8 NAME (First ; Middle,
<br />Andrew Enevoldsen
<br />Las
<br />Suffix)
<br />Be. APT. NO.
<br />1Ob. NAME OF SPOUSE (First, Middle, Last,
<br />Ann
<br />Harrold
<br />12. MOTHER'S -NAME (First,
<br />Esther Sonderup
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, give maiden name.:::.
<br />Middle,
<br />13. EVER IN MEL ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPO$$1710N -
<br />O Burial ❑ pons on
<br />Ciematiot ❑ Entor tbint
<br />O Removal ❑ other {Specify)
<br />14a. INFORMANT -NAME
<br />Angie Robertson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a.FUNERAL :HOME.NAME:AND MAILING ADDRESS (Street, City or Towtt State)
<br />AB Faiths Funeral Home, 2929 S. Locust Street, Grand Island,;; Nebraska '.
<br />CAUSE OF DEATH (See instructions and examples)
<br />ART i. Enter the chain of ohts--diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />'eepiratoryarrest, or ventdculer BOrIllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) cardiogenic shock
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />)ischemic cardiomyopathy
<br />ECITY#I
<br />YES C
<br />14b. RELA71SNSIUP TO OBOE
<br />Daughter
<br />16c. DAIS Itichp,Dior, Yr),<:;
<br />Sept l
<br />APP
<br />6 Dave
<br />set tot th
<br />DUE TO, OR AS A: CONSEQUENCE OF:
<br />E,nr ma,uND ,YINO;RUSE C) Acute anterior ST elevation MI
<br />s...
<br />(diasesa Or Injury that initiated
<br />the events resulting in death)
<br />LAST, ...
<br />PART 1) O: F MGNia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset toideath
<br />NT CONDITIONS Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />F
<br />20 IF FEMALE
<br />Not pregrtpf7S Wafi#f
<br />'P»gnapt ataies at
<br /><Not pregnatal but ptugaentwltlfin 42 days of deatit
<br />❑ ',Not pregnant, but pregnant 43 days to 1 year before death
<br />� Umlmewn ff((fPfitSIS WDfh n the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 HomIcIde
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide
<br />El not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />!I© Passenger
<br />0 Pedestrian
<br />o Other (Specify)
<br />19. WAS C(IE) CAI
<br />OR CORONEROONTAOTE
<br />❑ YES ;1I NO
<br />21c. WAS AN AUTOPSY PERFOR.
<br />YES
<br />21d. WEitE AUTOPSY )41401910.6 AVM
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 yE8 'Q NO
<br />22aDATE QF:INJURY (Mol:: Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF 1NJURYNAt home, farm, street, factory, office building, construction sits,*
<br />DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATtON OF INJURY STREET &NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 12, 2022
<br />L '
<br />a -
<br />CITY/TOWN
<br />STATE
<br />23b. DATE S)GNEED(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 13, 2022 01:22 AM
<br />N.
<br />Team best of fits imowledge, death occurred at the time, date and place
<br />arae due to titF.ttause(s) stated. (Signature and Tide)
<br />Erich R. Fruehling, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME tot
<br />24e. On the Beals of examination and/or investigation, In my da00i,4 tred
<br />the thud, date and place and due to the cause(e) stated. (Sigtuture 454 FWs)
<br />25.,DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN: OR TISSUE DONATION BEEN CONSIDERED?
<br />❑'YESNO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO
<br />2i S4AM8,'ii1 . ANt AG rtESS OF CERTIFIER (Type or Print
<br />Erich R. Fruehling, MD, 3515 Richmond Circle, Grand Island,' Nebraska, 68803
<br />f
<br />28a. REGISTRAR'S SIGNATURE
<br />26b.: WAS CONSENT GI!
<br />Not Applicable if 26a Is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 26, 2022 •
<br />c.n
<br />
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