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<br />-u STATE OF NEBRASKA „1
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<br />IEN THIS COPY CARES THERAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW T'O
<br />IE A TRUE COPY OP THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAN SERVICESVITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE 9FIMAN
<br />/1,9/2023'
<br />UNCOLIV, NEBRASKA
<br />202300513
<br />SARAH BOHNEN . .
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALT
<br />AND HUMAN SERVIC
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 peosoe VSNAME (Fret NlrlJdie, Leet, Suffix)
<br />9ary Lpre
<br />:Peace:
<br />4._CYIY AND STAfiE,ORI
<br />King CItYa:Callft9rtlt>i :+
<br />T SOCIAL SECURITY NUMBER`
<br />505.94 1 08
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />8b.;.FACILUTY-NAME (tf not
<br />2517 W dth St
<br />8c; CITY OR T'QWN OF DEATH (lnde Zip Code)
<br />• Qrand Island 68803
<br />9a.;RESiDENcE4?ATE';
<br />Nebraska
<br />STREET A#/O *�+040ER
<br />217 W �tfl i7t
<br />104. MARITAL: STATUS AT TIME QFC DEA.T11•10 Married 0 Never Married
<br />Married, but separated D Widowed":. 0 Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />E'1e
<br />ino
<br />.44401::
<br />Peal
<br />13 EVER IN 1) BAR
<br />(Yes;: No;`or'.Utik)'
<br />4Ta. UNERAL HOME.N4 M.E AND MAILING=ADDRESS (Street, City or Town State)
<br />).;Sl' Faiths Funeral Nome .2929 S. Locust Street, Grand Island Nebraska for
<br />IC fir (Spec)fv)
<br />CAUSE OF DEATH(SettY.MStructiOhsAnd examples)
<br />Last, Suffix)
<br />*AGE •Las( BII thday.
<br />(Yrs.)
<br />57 :<
<br />ie dates of service if Yes.
<br />a
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />3. DA:TE OF DEA
<br />Deceimber,3
<br />6: DATE Or eilt f:+.
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />(.:PLACE OF DEATH
<br />HOSPITAL O b patient
<br />ER/Ou patient
<br />Q 00A
<br />9c. CITY OR TOWN
<br />Grand Island
<br />18d. COUNTY OF DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />August 1
<br />OTHER 0 Nursing Ha
<br />®. Decedent's Home
<br />0 Other (Spout
<br />pe. APT. NO,
<br />?Ob. NAME 'OF'SPOUSE (First, Middle,
<br />Stephanie Schlueter
<br />12 MOTHER'S.NAME (First,
<br />Barbara Keliv
<br />14a. INFORMANT -NAME'
<br />Stephanie Peace
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE'
<br />68803
<br />Last, Suffix) If wife, give
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />Middle,
<br />CI1Y/TOWN
<br />Gibbon
<br />Malden Bumei
<br />te;,?ART); Enter the of events, dkisage8'; injuries,' or complications that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />.:. arrast,.
<br />nttkeuiaifiibilhatiem Without showing the etiology. DO NOT ABBREVIATE. Enter only onecause on a line. Add additional Tines if nacea
<br />EO)ATE CAUSE:
<br />alignant neoplasm of brain Gliobtastor a
<br />amaatATE0nt ss:(iz
<br />taaeaao or atnlit(tagtt,n
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />Ente thei1NDERLY1 .:::::
<br />(disetititi injuiiy Th t'Initfefei
<br />tare ereirla recut lng In death)'
<br />TO, OR AS A. CONSEQUENCE OF:
<br />AA
<br />OR AS A CONSEQUENCE OF:
<br />48 PARt ti *'THBR SIGNih7CANTCONDITIONS-Conditions contributing to the death
<br />,20 IF FEhAA-L
<br />(gat pregni
<br />Pregnant at tar
<br />D
<br />)lot Pregnant but pregrtarit widtbr42 dsys ofdeatll
<br />Not pregnant;:batpregnant 4s dayp to 1 year betore death
<br />D,tii**n lf.Pnignantwathm the that fear -
<br />Pa.. -DAT
<br />F f(kjURY#Mo,`Day Yr.):,
<br />224; INJURY AT'WORK?'
<br />XES.:;.
<br />N
<br />21a. MANNER OF DEATH
<br />® Natural D Homicide
<br />D Accident 0 Pending ImestigatiOn
<br />0 Suicide D Could not be determined
<br />not:resulting in
<br />22b. TIME OF INJURY
<br />22c. PLACE;OF I
<br />IBE HOW INJURY OCCURRED
<br />LOCATION OF IN,IUR"l STREET &:NUMBER, APT.NO.
<br />230;: DATE OF.'DEAiTH (Mo.,,Day, Yr.) •
<br />Decemberl31, 2022'=
<br />CITY/TOWN
<br />URY-At h:
<br />the uiiderlying cause
<br />iven in PART'f:
<br />21b IF TRANSPORTATION INJURY
<br />.D OrWetlOperator
<br />O.Pasaenger
<br />El Pedestrian .
<br />0 Other (Specify)
<br />•
<br />19. WAS MEDltt'AL ExAM R
<br />OR C GINTi01.00'.
<br />D'xEs:`:
<br />21c. ;NAS AN AuiPeSY SeasP
<br />D :Yes
<br />214. WEREA
<br />T4'Cl
<br />D:)
<br />e,farm, street, factory, office building; constr
<br />A
<br />STATE
<br />23b. DATE SIGNLD (Mo., Day, Yr.) ' 23c. TIME OF DEATH
<br />• January 5 2023: 04:53 AM
<br />Ta1he bestof myknowtedge, death occurred at the time, date and place
<br />anddue to lhiCeint a) afatetl::(Slgneture and Title)
<br />ven.Hisen M
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />244, TIME
<br />24e. Eire the basis of examination andlor investigation, in mi, Minion'
<br />time;'dete and place and due to tha.cauee(a) stater!. (S.igo
<br />D(p TOBACCO USE CDNTRIBUTE'T0:THE;DEATH? G
<br />YES NO ( PROBABLY .D UNKNOWN
<br />? NAME, TI'n.EAHD ADDREItS 0 CERTIFIER (Type or Print
<br />Steven Hien MC); 211.6'W Faidley #400, Box 9802, Grand Island, Nebraska'; 68:863
<br />26a. HAS OR
<br />DYES
<br />AN OR TISSUE DONATION BEEN CONSIDERED?
<br />511,$p-
<br />26b.
<br />1A:NO
<br />28b. WAS CONSENT(
<br />Not Applicable` If 28a
<br />28b. DATE FILED. ev.REGIS'
<br />January 17; 2023:
<br />
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