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<br />EN THIS COPYCARRIES THE RAISED SEAL OF STATE OFNEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />A,UE TROPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND ..
<br />UMAl `SERt#WES, ;VIT AL'RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />9.fl.E.GENT8
<br />Jesslf9 J
<br />4: CITYANfl STAY E G :TERRITO•RY OR: FOREIGN COUNTRY OF BIRTH
<br />2022.07 507
<br />exiicA
<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 />Iddle, ' Last, Suffix)
<br />DC(AL 8EC4 01.* NIP
<br />t<ACIUTYNAME (tf nbt:tnstltution'
<br />Irl St t;ranols
<br />8b:
<br />Hr Hea
<br />BER
<br />CITY OR 701594 Ot ")EAT
<br />Sra(id Island 68 08
<br />9a. RESIDENOR-
<br />ebraskta ..:.
<br />ATREET )0100
<br />root and number)
<br />5a. AGE - Last Birthday`
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PI -ACE OF DEATH
<br />HOSPITAL ®Inpatient
<br />0 ER/Ott patient
<br />0DOA
<br />T!'At STATU$ AT:T1MAE'
<br />ac
<br />9b. COUNTY
<br />Hall
<br />DEATH'® Married 0 Never Married
<br />idowed 0 Divorced 0 Unknown
<br />Last, Suffix)
<br />9c. CITY OR TOWN
<br />Aida
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />S.
<br />MIN
<br />OTHER 0 Nursing
<br />O Decedent's Horn
<br />❑ Other (Specify)
<br />319:6
<br />• 3. DATE OF DE.ATN4511o.; say Yf)>.
<br />Septler 2S '2592
<br />6 -DATED!
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Kenneth Saner
<br />Ittirp :5#a
<br />12 MOTHERS=NAME (First, Middle,
<br />Fitfrenoe Bartholow
<br />•EV/ER tl+f tl.S: AI
<br />(Yes No, or lie It
<br />8? Give dates of service If Yes.
<br />METHOD c F p4SPOSITION
<br />J Burls# oo�natton
<br />•
<br />'Crematicfl Entott4#rn
<br />14a. INFORMANT -NAME
<br />Kenneth Saner
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />18d:CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />}'Rtf{TioYa) (5ther:{Specilyj ,
<br />F
<br />1 Vllestiawn Memorial Park Crematory Grand Island .
<br />0)1. AL k#OME 04/)E AND MAILING ADDRESS (Street, City or Town, State)
<br />lvinastor Orideritiann Funeral Home; 601 N. Webb Road, Grand Island, Nebraska
<br />Tl Ether
<br />CAUSE OF DEATH (See instruet#ons and examples)
<br />.diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ftrM ventr wr4atrinatmn without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />Hypoxic Respiratory Failure
<br />St
<br />amenft
<br />14b. RELATI
<br />Spouse
<br />lac DAM
<br />SeOtetzl
<br />NT"
<br />At8 oAUEt
<br />fermi ilii rezii
<br />d
<br />auannailfy.11tca
<br />any, leaallely. to tele ce
<br />'DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Diastolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E 0) Pneumonia
<br />I
<br />PART II OTHER.SIONIO
<br />TO, OR AS A CONSEQUENCE OF:
<br />Debilitation
<br />T CONDITIONS -Conditions contributing to the death
<br />and died in the hospital
<br />42daysef death :
<br />td t year before death
<br />22f 4OCATION`OF I
<br />21a. MANNER OF.DEATH
<br />Natural 0 Hotniblde
<br />0 Accident 0 pending InVetidgetion
<br />0 Suic de Could not be determined
<br />fres
<br />ngan tho underlying cause given In PART I.'
<br />•
<br />•
<br />22bt TIME OF INJURY
<br />22c. PLAC..
<br />22*. DESCRIBE HOW. INJURY OCCURRED
<br />tET.8, NUMBER, APT.NO. CITY/TOWN
<br />)EATH (Mo.; Day, Yr.)
<br />er26� X2022
<br />3b DAT$ SIl2NED (Mn" flay Nr:) : 23c TIME OF DEATH
<br />t pptterliber 2b 2 01:54 AM
<br />3d the badta:myknowledge, death occurred at the time, date and place
<br />•.add die totheisu4e(aj'etaled. (Signatureand Title)
<br />Fi'eet A DOrtrler MD ':
<br />TE To THE DEATH?
<br />ABLY, 0 UNKNOWN
<br />iL A(IIAl;RESS 6F CERTIFIER (Type or Print
<br />I61iner4MD, 729 North Custer Avenue, Grand Island, Nebraska:, 6880
<br />REGISTRARSSIGNA URE •
<br />F IPi.#URY-
<br />28a. HAS ORGANO
<br />0 YES
<br />21.b, fF TRANSPORTATION INJURY
<br />.0 Dtivetioperator •
<br />l0 f ieeenger '
<br />0 pedestrian
<br />0 Other (Specify)
<br />t home,;
<br />21c. WAS AN AUTOPa't'PERt9Ml
<br />Q..YEs.....:
<br />21d. WERE AUTO
<br />•
<br />•TO COMPLETE.
<br />0 •Yss
<br />rm
<br />tteet, factory, office building, const
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />FINDINGS AtrAit.A15I;E.
<br />AUEE' DEATH?
<br />S
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />216,.744.4.
<br />24d. TIME PRONOUNyCED.:
<br />240.On the basis of examination and/or investiga ion, in'my opinion.'deeVt edou.
<br />Valetta, date and place and due to the cause(a) stated. (Signature add 1Nlle} `<.
<br />R TisauEare ATION BEEN CONSIDERED?
<br />28b. WAS CONSENTAIRANTED?::
<br />Nbt Applicable' if 26a ia,
<br />28b. DATE FILED BY. REGISTRAR (Mo., Day, Y
<br />September. 28, 2022
<br />)
<br />
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