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<br />STATE OF NEBRASKA _. )
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<br />+l+ttEN 7HlS 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 me NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAN`'SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />DA
<br />rE OP ISSUANCE
<br />2/22/2022
<br />LINCOLN, NEBRASKA
<br />202208844.
<br />MCA Latif
<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 />22 02292
<br />1. DEOEDENT'S-NAME (First, Middle, Last, Suffix)
<br />Shirley Merle Stalk
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Otoe, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-35.4997
<br />2. SEX
<br />Female
<br />5a, AGE - Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Riverside Lodge, Inc.
<br />c,=CITY Ori TOWN OF:DEATH (include Zip Code)
<br />Grand island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d; STfiEtiT ASVD NUMB.SR
<br />5679 SOutt(North Road
<br />c
<br />u
<br />dt
<br />CAUSE OF DEATH (See instructions. and examples)
<br />18. PART1. Enter the chain of events- ,diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />85
<br />8a PLACE OFDEATH
<br />HOSPITAL Q inpatient
<br />9b. COUNTY
<br />Hall
<br />Q ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island`
<br />3. DATE OF DEATH (MO:, Day, YF}.
<br />February 10, 2022
<br />B. DATE OF BIRTH (Mo.,
<br />December.:81, 1:.936
<br />fl Hoeptce Fe.cEt y
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Speciry)ASSISTED LIVING
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT.
<br />NO.
<br />9f. ZIP CODE
<br />68803
<br />. MARITAL &TATUO ATTIME OF DEATH 0 Married 0 Never Married 101s. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown Norman Stelk
<br />FATHERS NAME (first, Middle, Last, Suffix) 12. MOTHER'S,NAME (First, Middle, Maiden Surname)
<br />Henry John Hornfeld Ruby Marie Schmidt
<br />13. EVER IN US ARMEDFORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />1S. METHOD OF DISPOSITION
<br />I Butlat Q Donafton
<br />o Cramatlon Q Entom€finettt
<br />❑Removal : jJ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Sharon Kruse
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranlo
<br />16b. LICENSE NO.
<br />1071
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />AIF Faiths Ftlnerai t4ome, 2929 S. Locust Street, Grand Island,'Nebraska
<br />t:;
<br />MD
<br />IMMEDIATE CAll8E (Finst
<br />dla0abe or onndttlpn respain9 .:
<br />Sequentially Ilst conditions, It
<br />any, lading to the cause doted
<br />on got e
<br />Enact fire t1N..DEitti !NO t:'PUINI
<br />(alse8sacr Injulg.hat Initiated.
<br />the events resulting in death(
<br />IMMEDIATE CAUSE:
<br />a) acute myocardial infarction
<br />14b. RELATIONSHIP TO DEt,.tcCENT::
<br />Daughter
<br />18c. DATE (Mo., Day, Yr.)
<br />February 16,.2022:::.
<br />STATE
<br />Nebraska
<br />1Tb ZipCode:,:
<br />68801 '...:.
<br />APPROXIMATE INTERVAL
<br />onsetto
<br />10 MtnuteS
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary Artery Disease
<br />onset to death
<br />15 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d),
<br />onset to death
<br />18 taART (t. OTI .ER S(GN(F(CANT CONDITIONS -Conditions contributing to the death but. not:
<br />Permanent Atrial Frhrlllation
<br />0. (F FEMALL
<br />Not ereppedt ctthin path yt
<br />O Pregnant at Hine dr d4ath
<br />❑ iiigf pteortao but preorlant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />suiting in the underlying cause given In PART 1.
<br />21a. MANNER OF DEATH
<br />Naturaf ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not ue detetmined
<br />21b. IF TRANSPORTATION INJURY
<br />Drtver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (tipecify)
<br />19. WAS MEOICAt EXAMINER
<br />OR CORONET$ OONTAGTED
<br />❑ YES Ea NO
<br />21c. WAS AN AUTOPSY PERFOR
<br />El TES IZINQ
<br />21d. WERE AUTOPSY FINDINGS AVAttJU
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES0N
<br />22a; LATE OF4 PR.Y(Mo Day, Yr.)
<br />£ 22d. INJURY AT WORK?
<br />d
<br />c
<br />a
<br />AYES 0 N
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION`OF INJURY'': STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITYr#OWN
<br />February 10, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />12:30 PM
<br />u February 15, 2022 rTa iiia best of sty t{nowledge, death occurred at the time, date and place
<br />2 and due tD the causes) stated. (Signature and Title)
<br />Garv'Settle, MD
<br />hoMB, farm, Street, factory, office building, construction site, etch (SlAmcglf)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD.
<br />• O t the bah(e of examination and/or Investigation, M my opkilon teeth Orderer/ at
<br />tite tMte, date and place and due to the cause(s) stated. (Signature enema)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES in NO ❑;PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />27. NAME.i.:I LEAND ADDRESS OF CERTIFIER (Type or Print
<br />Gary 5ettje MD, 2'116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is. NO Q YES
<br />C3 NO::.
<br />28a. REGISTRAR'S SIGNATURE
<br />i .6arczk;c
<br />28b. DATE FILED BY REGISTRAR (Mo.,;Day, Yr.)
<br />February 15, 2022
<br />cD
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