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STATE OF NEBRASKA
<br />dt,
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<br />'El',' THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TC
<br />A TRUECOPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />MAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />. .
<br />LINCOLN, 0..00674$
<br />&L414
<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 />EDNFirt, Middle, Last, Suffix)
<br />4ciTY:41IN,D STATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha Nebraska.
<br />7::$0014gEookrfrN4m0ER'':;,,,
<br />40645-084'••••:':::,gi"-','
<br />813.:FACILITY•NA5AE011ot Institution, give street and number)
<br />CHHiealtil Beroan Mercy
<br />liCiATY.pg.79061:,..Ir'ogi:.9•H(incitacie Zip Code)
<br />;$01245gi"'.'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Merrick
<br />2. SEX
<br />Male
<br />3. DATE OF peovefiteo.,..06,
<br />5/1.AGE • Last -Birthday.;
<br />(Yrs.)
<br />j. 9d.STREET4N*IMBER
<br />.g 't072 5th Road
<br />.10;imAkitAe4ii:Aiiiii*TIME OF DEATH 0 Married 0 Never Married
<br />A5i3 Named, but separated 0 Widowed 0 Divorced 0 Unknown
<br />el; 11. EATHEWS-NAME Middle, Last, Suffix)
<br />Bernard Campbell
<br />72
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />PLACE OP DEATH
<br />'17.1 inpatient
<br />0 ER/Outpatient
<br />•...DDOA
<br />Sc. CITY OR TOWN
<br />Chapman
<br />18d. COUNTY OF DEATH
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (MO., 08 -Tr.)
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />Douglas
<br />Be. APT. NO.
<br />Of. ZIP CODE
<br />68827
<br />fliONSIDBOas N0
<br />OITYLIMITt.
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Sherri
<br />Smith
<br />I12, MOTHER'S -NAME (First,
<br />Mavbelle Petersen
<br />Middle, Malden Surname)
<br />t3.EVSR IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14e. INFORMANT -NAME
<br />Joyce Meinecke
<br />14b. RELATIONSHIP T011EadiEte.
<br />Power of Attorney
<br />: 15. METHOD OF oisposmoN
<br />(specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ra.euNgeAL-Nolegimuee AND MAILING ADDRESS (Street, City or TowN;Stata)•
<br />NVFettilt:EOneret:HOme, 2929 S. Locust Street Grand Island Nebraska :•••••]•
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />18c. DATE (Mo
<br />Novembit43zur4
<br />Nebraska
<br />•
<br />S. PART I. Enter the chain of events- -diseases, Iniudes, or complications.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrMatIon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />• •-• IMMEDIATE CAUSE:
<br />imississr8 CAtisErMnal a) cardiac arrest
<br />disease or conditIon resulting
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)hypoxia
<br />any, leading tattle cascaded
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eatintaa:i***945088 C) aspiration
<br />hquiyiliat Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)traumatic intracranial hemorrhage
<br />18, FART OTHER stompicANT CONDITIONS -Conditions contributing to the death but not resulting lathe underlying cause given in PART I.
<br />encephalopethy sssendan/ to uremia and acute kidney injury, MVC causing cervical spine fractures, vertebral artery injury,
<br />lumbar spine fracture, pulmonary contusion, sacral fracture, left acetabular fracture, left tibia and fibula fracture
<br />20. i!...PEMALE•
<br />ot pregnant istthilafeat year
<br />birmi.,!..*45111H.
<br />42
<br />, days of death
<br />0 Not pregnant,
<br />but pregnant ee gays tot year before death
<br />•:?.,[a.:...Ynitheethg•Artdintiid:WORIiititepast year
<br />• • • • • .• • • • ,
<br />; i:le;DATEQFIH:iiiili43'ifAri.,•Day, Yr.)
<br />October 28, 2.on
<br />22d. INJURY AT WORK?
<br />NO
<br />„47
<br />21a. MANNER OF DEATH
<br />Natural 0 tiontiqide
<br />Accident 0 Fending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />12:1
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onset
<br />onset to death
<br />Minutes
<br />ansett#000
<br />MinutOSIE.'
<br />onset to death
<br />Daya-
<br />19. WAS MED(CAL 1DrAMINER
<br />OR CORONER -CONTACTED?
<br />gives DM0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES 0440..
<br />21d. WERE AUTOPSY RNDINGSAVAILASLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES 0:NO • .:.:
<br />22b. TIME OF INJURY
<br />06:56 PM
<br />22c. PLACE.:OF INjURTAt lioilIe,'fann,''street, factory, office building, construction IlKe,
<br />....„::..;.;:.
<br />Highway •14::=
<br />228. DESCRIBE HOW INJURY OCCURRED
<br />two car wreck on highway
<br />22TIOCATION OF INJURY STREET & NUMBER, APT NO CITY/TOWN
<br />U Hkihway 39 E And Stuhr Rd S, Grand Island
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 22, 2022
<br />23b. DATE eiaasp (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Datettbert .2022 06:55 AM
<br />TOIN btakt of My knowledge, death occurred at the time, date arid place
<br />iind **lb die Oluu(s). stated. (Signature and Title)
<br />Jessica M Veatch, MD
<br />STATE ZIP CODE
<br />Nebraska 68801
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PROKYNCE.R.DEAD„:.....
<br />ate Op thqbable of examination and/or investigation, In my opinion dettikbgbitedbr,
<br />•.1:] • tbellittri. date and place and due to the cause(s) stated. (signature dirlitjrtie)
<br />al DIP1PsACCOUSS::OONTIkIDUTE TO THE DEATH? 26a. HAS ORGAN OR TISSU,EDOHA711914tBEEN CONSIDERED?
<br />:FROBABLy Cl.
<br />itl,:.:.7;i0i,-.:,,$ 00,,,,.. UNKNOWN 0 YES ':, :::i
<br />, , , , ,,..,
<br />11-..NAME.:-IFTWAlliD:AtrormEss or CERTIFIER (Type or Print
<br />..„,,,,
<br />;"i:::",•:'':'. ;•::::: ;-.:jeliBitargIVeattiffi'MD,1000 Mercy Rd, Omaha, Nebraska; 66124 '.•
<br />.. . .
<br />REGISTRAR'S StGNAtUI
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.), •
<br />December 1 2022
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