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<br />STATE OF NEBRASKA
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<br />111 THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, 1? CERTIFIES THE DOCUMENT BELOW TO
<br />A TRt/ECOPYiOFTHEORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND .:.
<br />AN SERVICES, VITAL RECORDS: OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OFISSUANC
<br />1 /1 at2a22
<br />NCOLN$ NEBRASI
<br />202300330
<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 />pBCEDENT'S NAME (.,t'4t, Middle,
<br />,Jaron e. Henry Brand
<br />C(TY AND TA E OaleftarrOR`I;:OR FOREtGN COUNTRY OF BIRTH
<br />Last, Suffix)
<br />:IAL SECURITY>lii(J
<br />5a. AGE - Lasts rittday.
<br />(Yrs.)
<br />83
<br />8c CITYOR";T ISN C
<br />G.rand.ls1a nd;`#
<br />92f RESIDENCESTA
<br />Nebraska
<br />I i' STri4,
<br />4f19,Sa
<br />Bb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />22:.'t5i
<br />3, DATE OF.E.AT14IMo .
<br />November 3r 2O22
<br />8. DATE OF BSlRTf} into.: Day. Yt'3'
<br />8a PLACE OF tATH
<br />HOSPITAL El•
<br />ktpaUeut
<br />❑ ER/Outpatient
<br />DOA:::.
<br />OTHER ❑ S(tursing
<br />❑ Decedent's Harps
<br />❑ Other (Spe
<br />8d. COUNTY OF DEATH
<br />Hall
<br />�Ntk, EUMBEt
<br />nd{eWOQtn
<br />9b. COUNTY
<br />Hall
<br />US AT TAME OF DEATH, Married 0 Never Married
<br />Widowed , 0 Divorced 0 Unknown
<br />h`' ThER`S-NAME
<br />harles H ;: E
<br />3.EVER
<br />CE
<br />6
<br />?•• Give dates of service if Yes.
<br />$)1958-04/01/1960
<br />9c. CITY OR TOWN •
<br />Grand Island
<br />`t. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1(Ib. NAME•OF SPOUSE:(First, Middle, Last, Suffix) Ifwife,'g
<br />Barbara Baxter
<br />14a. INFORMANT -NAME
<br />Barbara Brand
<br />16e.EMBALM ERSIG NATU RE
<br />Katie M. Smvdra
<br />12 MOTHER`S NAME (First, Middle, Maiden•
<br />Sums
<br />;Lena May Carman
<br />l8d. CEMETERY, CREMATORY OR OTHERLOCATION'<,
<br />Central Nebraska Cremation Services
<br />1.6b, LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />17a FLl)YkRAE HOME NAMEAND MA(UNGADDRESS.(Street, City or Town, Elate). •
<br />Alt Faiths F i rerat Home 2929 S Locust Street Grand Island, Nebraska for
<br />tier •($0 Y)
<br />' CAUSE OF DEATH (See Instructions artd -examples)
<br />\i
<br />1.Enter the thein Rf:e;4eete. .diseases, Uqudee, or comptications.that directlyicaused the death. DO NOT enter terminal events such as cardiac arrest,
<br />Ihtion Without showing the etiology. DO NOT ABBREVIATE. Enter Only one cause on a line. Add additional Tines If necessary.
<br />IMMEDIATE CAUSE:
<br />) Cardlacarrest.
<br />tNtdEDItTS t Au6E tt•indtl
<br />4lseaetE er eontrttten rtiMuHOi
<br />Mt
<br />:,tSequenttally.hat
<br />e ... Ieudifig:ta die x
<br />wt
<br />sat te4 '
<br />nR AS A CONSEQUENCE OF:
<br />Drury Artery Disease
<br />Entat:t/Fe:UND6RI
<br />'tdtsease i'li?7d!Y
<br />_;.dee eeenta.resulni
<br />TO OR AS A CONSEQUENCE OF:
<br />TO, OR AS,A:CONSEQUENCE OF:
<br />AV_ )t OTH.R SIGNIFICANt rrONDITIONS-Conditions contributing to the death butriot tesulting in iltz underlying cause given in PART 1, `
<br />eSiatOit( ALtltritis Peerjpherai vasoular disease, Carotid Artery Disease, Chronie Kidney Diss ase'
<br />Jaya of death : • ..
<br />tP 1: year 'before death
<br />ala'
<br />210. MANNER OF..DEATH :.
<br />Natural 0 HOmictda
<br />0 Accident 0 Pant 1nveatigetien
<br />0 Suicide ❑ Could not be determined
<br />..2.11).,4B:::TRANSPORTATION INJURY
<br />❑. D*ivgdOperator
<br />Q:.Peseenyer:
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY -At 110035,
<br />21e. INAS'AN A
<br />❑. YES
<br />t street, factory, office building, cons;
<br />con
<br />22d
<br />WORT AT
<br />2e DESCRIBE HOW INJURY OCCURRED
<br />TREI*T&'NUMBER, APT.NO.
<br />TH (M0 , Day, Yr.)
<br />3,
<br />23b {PATE StGNED.(Mo Day Yr.)' 214, TIME OF DEATH
<br />efnler,8'<202 11:29 AM.
<br />::hestoftnp knoti,led'pe,deatti.occurred et the time, date and place
<br />a tp ttnt (abet (alptated, (Signature and Mel
<br />CITY/TOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME Of= DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />O
<br />nni#i
<br />;t;t1 USE CON'
<br />fi 4
<br />240, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />An the baste,of examination and/or investigation, in my optnton de*ttt dC
<br />the tlma; vete and place and due to the causes) stated Mignatura an4
<br />le TE TQ':THE DEATH? 28a. HAS ORGAN OR
<br />ROSABLYCEi1TIF1 UNKNOWN 0 YES
<br />NAM`~ TITLE AND ADDRESS OF R (Type or Print
<br />Jer(rlifet !,..Brown, MO, 729;,North Custer Avenue, Grand Island;` Nebraska 68803'
<br />8a REGISTRAR.'$ S(GNATtI
<br />SSUEDONATION BEEN.CONSIDERED?
<br />26b. WAS CONSENT ORAN
<br />Not Applicable if 265 is NO
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 14, 2022
<br />
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