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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />►UMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />5/1412022
<br />LINCOLN, NEBRASKA
<br />4. DECEDEND$ NAME (First,
<br />I Obert . ErrtAOfikOtilek
<br />Middle,
<br />202207520
<br />A{?f
<br />SARAH BOHNENKAMP j
<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 />Omaha, Nebraska'.
<br />T ;&Cic IAL::3ECURITTNUMBER
<br />06-4-2105
<br />85. AGE - Last airthday
<br />(Yrs.)
<br />g
<br />V
<br />e
<br />C
<br />8b:,PACILITY•NAME (It not
<br />3015 W Tenth Street
<br />tution, give street and number)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 688133
<br />9a. RESiDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3015 W Tenth Street
<br />9b. COUNTY
<br />Hall
<br />85 .
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1'' DAY
<br />MOS.
<br />DAYS
<br />SL.IPLACE OF DEATH:
<br />HOSPITAL ❑ lnpetimit
<br />0 ER/Ou patient
<br />0 DOA
<br />10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER 8 (ftAMla (Fi
<br />Emil Karnak
<br />Iddle,
<br />Suffix)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (M
<br />May 3,'20:22
<br />05i+ Y
<br />8. DATE OF BIRT.R Mo., Day Yr.)
<br />June 12; ::1936;::
<br />OTHER 0 Nursing Home/LTC'
<br />au Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />;Ig, INSIDE CI'iri.EMTS
<br />10b. NAME OFSPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Catherine A Goering
<br />13 :EdER IN t Ss ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No. or Unk.) Yes 10/31/1958-10/30/1960
<br />15 METHOD OF DISPOSITION
<br />'":Burial ❑ Donatlan
<br />Cretnatoi [❑ Erwtombffient
<br />:Rarftovai ❑Otber(Specify)'
<br />14a. INFORMANT -NAME
<br />Catherine Kutilek
<br />12. MOTHER'S -NAME (First,
<br />Ann Cervenv
<br />15a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION 3:
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State),
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />CITY I TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT"
<br />Wife_ -
<br />180. DATE (Met
<br />May 4.02
<br />CAUSE OF DEATH(See instruction
<br />iwl examples)
<br />13. PART I. Enter the chain of events. -themes, Injuries; or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />resOratory arrest, or venMfuiar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional linea if necessary.
<br />IMMEDIATE CAUSE:
<br />woman CAU$13 (tnnat '> a) chronic heart failure
<br />disease or ddnditieo moulting....... ....... ...:... ...............
<br />................. ...... ................
<br />Indeetnl
<br />Sequentially list conditions
<br />any, leading to the cause lie
<br />Enterthe U 4001. 14,.e Ise
<br />(disease or Injury: that initiated
<br />UE TO, OR ASA CONSEQUENCE OF:
<br />b)Coronary artery disease
<br />STATE
<br />Nebraska
<br />•.Tb. Zip,Cata,;;;
<br />S88Oi
<br />APPROXIMATE INTERVAL
<br />onseftOde$h:
<br />2 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />•18 PART IL OTHER SIS,NIFiCANT CONDITIONS -Conditions contributing to the death but not resulting In the Underlying cause given in ;PART I.
<br />chronic kidney dieease' atrial fibrillation , hypertension
<br />20.IF,FEMALE:
<br />Op-{ Not.pregnantv/ithlh p y!
<br />Pregnant a1 titae of cloaUt
<br />❑ 1!lEE paagnant but Preggent within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If:pregnant within the past year
<br />22a.: DATE OF .4,May (Ma, Day, Yr.)
<br />22d.'INJURY AT-WORK:i
<br />❑ YES ❑ NO
<br />2:
<br />21a. MANNER OF DEATH
<br />Natural ❑ Horn citle ..
<br />0 Accident ❑ Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21.b.;IF TRANSPORTATION INJURY
<br />:❑ Drlver/Operator
<br />:❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MED10.1.'EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES` ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AuToi*Vmsloallot AVAILABLE
<br />TO COMPLETE CASE OF DEATH?
<br />❑ YES O. NO ....
<br />22c. PLACE OF INJURY: At ltd e, farm, street, factory, office building, construction site, lg
<br />e. DESCRIBE HOW INJURY OCCURRED
<br />2f LOCATION OF INJURY- STREET & NUMBER, APT. NO.
<br />2
<br />. DI
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 3, 2022
<br />23b. DATE SIGNED'jMo., Day, Yr.) 23c, TIME OF DEATH
<br />May 4,:.2022 08:45 AM
<br />at Ththe Nasi of my knowledge, death occurred at the time, date and place
<br />end due tothe xause(s) stated. (Signature and Tale)
<br />Ryan D Crouch, DO
<br />ISmicifyt
<br />CITY/TOWN
<br />TOBACCO USE CONTRIBUTE' TO THE DEATH?
<br />YES NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUN
<br />D -DEAD
<br />24e. ("lathe basis of examination and/or investigation in my opined) deaib atcbired at
<br />the time, date and place and due to the cause(s)stated. (signature ferric le)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES j NO
<br />27• NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Crouch, DO, 800 N Alpha St, Grand Island, Nebraska;' 68803
<br />1285.
<br />REGISTRAR'S SIGNATURE U d
<br />26b. WAS CONSENT GRANTED? .
<br />Not Applicable If 285 is NO ❑ YDS
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 10, 2022
<br />
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