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<br />STATE OF NEBRASKA R,,,,bk,piN1u111u1/,�0 r/, as Olt ..'.f;
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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 OP 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 />•
<br />1N11•N1(lii�,Fl, 6°p Ili�elalalik: 4f„�yl/raal.
<br />DATE QFISSUANCE
<br />......................................
<br />/3o/2022
<br />LINCOLN, NEBRASKA
<br />�i
<br />cl ,
<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 />1. RECEDEI°Ir NAAME (hat, Middle, Last, Suffix)
<br />Takeo UtSumi
<br />CERTIFICATg OF DEATH
<br />4. CITY AND STATE OR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Japan
<br />7. $OCIAL,BECURITY NU:MSER
<br />508 5fi-181
<br />11 8b. FACILITY -NAME (if not Institution
<br />923 West.5ttf
<br />9c
<br />CITY OR 600N Q DEATH (Include Zip Code)
<br />Grand Is td '88803
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />ye street and number)
<br />$4
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSP TAL ❑ .Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9e. RESIDENCE -STATE
<br />Nebraska,`
<br />9d S REE4'AND NCt do
<br />923 st 15ttt
<br />10a.' IARITAL S'T'ATUS AT TIME OF DEATH ®Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />11 FATHER S -NAME (First, Middle, Last, Suffix)
<br />Masafrlt tJttrrtl <.
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, NA, :or.Unk.) No
<br />15. Tit] k3F 131SPOSITION
<br />sailer ;€ ❑ Donation
<br />Cremation 0 Entombment
<br />• 0 Removal `Outer (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />2'I
<br />10'
<br />3. DATE OF DEATH1M0.,D*Y
<br />Septembe $1 2022
<br />6. DATE OF $IR'('Ih ftAo., Day, Yt:)
<br />OTHER 0 Nursing Home/L.
<br />El Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai
<br />Kathleen Kamper
<br />1Z. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Halve Motova
<br />14a. INFORMANT -NAME
<br />Kathleen Kamper
<br />1Ea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />1Ta ;FUNERAL'HOME t9AME AND MAILING ADDRESS (Street, City or Town, State)
<br />t41I Faiths unerai klome, 2929 S. Locust Street, Grand Island. Nebraska
<br />Gibbon
<br />CAUSE OF DEATI4 (See Instructions and examples)
<br />Sit PART L Enter the; In of events• -diseased, Injuries, or compllcstlons.that directly caused the death. DO NOT enter terminal events such as cardiae arrest,
<br />respkftory sliest, 6r ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATRCALS
<br />it*lmse 1yr pon{j({km restuiii
<br />ht draft)
<br />Sequentially list conditions, If
<br />any:i*44If. totltltseutd(nibs
<br />(disease or hifg
<br />the events reed
<br />LAST
<br />18 PARTE::C
<br />IMMEDIATE CAUSE:
<br />a) aizheimers dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) diabetes
<br />DUE TO;
<br />aides o) hyper
<br />nitlSted
<br />G
<br />ASAI CONSEQUENCE OF:"
<br />rasion
<br />DUE TO, OR AS`A CONSEQUENCE OF:
<br />d)transient ischaemic attack
<br />14b. RELATIONSHIP TO L')S+GL'st*NT;'
<br />SPou
<br />IFICANT CONDITIONS -Conditions contributing to the death but notresuttinglin the underlying cause given in PART I.
<br />20 (F: PENAL.a.$
<br />N pr4grrangwxuutpaMyear
<br />P reedist sf:#na df de4tit<
<br />Net pregnark but pregneM within 42 days of death.
<br />0 Not pregnant, but pregnant 43 days tot year before death
<br />Wnknewn Fipregnattivlllltln the past year
<br />22a DATEOF.)N,lURY(Mo Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ ACGident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INd
<br />21b IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />5 Veers
<br />onset to death
<br />5 Years
<br />19. WAS Ak E)tAMMtER:
<br />OR O tTACTSGy'
<br />© NO
<br />21d. WERE AUTOPSY GS AVM)
<br />TO COMPLETE CAUSE OF DEATH
<br />0 YES [ NO
<br />URY•At homsiarm, Street, factory, office building, construction
<br />r, etc ISPOCNYI
<br />RLE
<br />22f. L ACATiOIN lF 1N 1:13
<br />STREET & NUMBER, APT.NO.
<br />29a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 2022
<br />23b, DATE 8IG.NED (Mo., Day, Yr.)
<br />Septa) e 21, 2022
<br />Tpths beatof tny.kncwtadge loath occurred at the time, date and place <:
<br />83 it+xre5itaS:icause(s)stated.Isignetureand Title)
<br />meth Vetted, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />11:50 AM
<br />25. DID TOBAC.r.O USE::CONTRIBUTE TO THE DEATH?
<br />YES NO Q PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME CEDDEAIQ::.
<br />•i
<br />24e.On thebeSis of examination andtor Investigation, in my eptillee
<br />:the rad, date and place `and due to the cause(s) stated. (9igtn
<br />s HAS ORGAN -OR TISSUE DONATIONBEEN CONSIDERED?
<br />28
<br />0 YES
<br />I:d
<br />27. NAME; TITLE AND ALIDRESs OF CERTIFIER (Type or Print
<br />Kenneth Vette(; MD, 2116 W Faidley #400, Box 9802, Grand Island, >• . ka, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSATGRANTED? .
<br />Not Applicable If 26a Is NO US
<br />28b. DATE FILED BY REfetweiseue (Mo«
<br />September 26,2022,; ..
<br />CSI
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