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<br />.WHEN €THIS "COPT CARRIES THE RAISED SEA:OF THE' STATE OF NEBRASKA,
<br />GERi.1.0iS THE DOCUMENT BELOW TO BE A TRUE COPY OF , THE ORIGINAL RECORD
<br />N`FILE WITH TKE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,
<br />EC,ORDD5 OFFICE WHICHIIS' THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202300519
<br />SARAH BOHNENKA)V
<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 />1: DECEDENT'S
<br />Darrel Lee
<br />E ;(FI
<br />1oe
<br />Middle,,
<br />Last, Suffix)
<br />4 GfTYAND STATE ORTERRIT.ORY; OR FOREIGN COUNTRY OF BIRTH
<br />• 6
<br />ood~River, Nebraska
<br />7 5[iplA(40..URr NUMBER 1
<br />506.5048904
<br />8.b,"FACILIw44AME0not Inch
<br />i1.Health":St) Franc)
<br />on, give street and number)
<br />c :CITY OR TOWN OF DEATH
<br />Grand (s(ai)d 68803'
<br />9a. RESIRENCE.StA?E;
<br />Nebraska
<br />9d STREET AMD NUMBER
<br />x:1810 S 1r4E th Road
<br />MARITAL:: STATUS AT.
<br />+ 11 FATHERSIAME (First
<br />RUdO(Dh . t Gloe !'..
<br />13. SV
<br />i (Yee
<br />Sa. AGE ..... Birthday
<br />(Yrs.)
<br />83
<br />hide zip Code)
<br />5b UNDER1YEAR
<br />MOS. DAYS
<br />Ba. P# ACE OF DEATH....:;:
<br />HOSPITAL ®:Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />ME OF DEATH ® Married ` 0 Never Married
<br />Widowed 0 Divorced 0 Unknown
<br />middle ' Last, Suffix)
<br />R )NUS ARMED,FORCES? _Gi
<br />No, or.U))k.):NO:
<br />5. METHOO:.OF:DiSFOSITIONJ
<br />Sufis) QDOna ion
<br />Cremation ❑ Entombment
<br />Removal ❑ Other (Specify)
<br />dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Wood River
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY •
<br />HOURS MINS.:
<br />OTHER 0 Nursing
<br />❑ Decedent
<br />❑ other (einem
<br />3. DATE OF'bear)t1Sa.,Uaiy
<br />June 7 2021
<br />6. DATE tOF'BIRTH (Ma., Day,:
<br />Home.
<br />8d. COUNTY OF DEATH
<br />I
<br />Hall
<br />9e. APT. NO.
<br />1Ob. NAME OF SPOUSE:;(Rrst, Middle, L
<br />Sharon Wiese
<br />14a. IN Fc RMANT-NAME
<br />Sharon Gloe
<br />lea EMBALMER -SIGNATURE.
<br />Brandon S Bachle
<br />184. CEMETERY, CREMATORY OftOTHER LOCATION
<br />•
<br />Wood River Cemetery
<br />9f; ZIP CODE
<br />68883
<br />ffix) If wife,
<br />DIN
<br />INSIDE OM LIMIT&
<br />❑ YES 50 NO
<br />name';
<br />12MOTHER'S-NAME (First, Middle,:
<br />Mildred C Kunz
<br />17a:. FUNERAL:HOMENAME AND:MAILING ADDRESS (Street, City or Town, St
<br />Apfa} Funeral Ht l71e, 11231N. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1537
<br />CITY f TOWN
<br />Wood River
<br />14p. RELATIONSHIP TO DeeepaNT
<br />Spouse
<br />1.fic, GATE tf4o Dt
<br />June 1 2O.
<br />,Yr
<br />' 1/1L•zip Cod
<br />88801:..•
<br />;::
<br />CAUSE OF DEATH (SaeinstrulctIOns.arid example&)
<br />5.PART I Enteti(t9.chairi.ofevents- igaeases,.injurlee,"or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reppiratory arrest, orveinricular fibrftataon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add edtlhionai lines if necease
<br />IMMEDUtTE CAUSE:
<br />a) Dementia And Neurocognitive Decline:
<br />4dmE))*TECACiSE (Ffa#
<br />disease ar eoru((tion te;ukaie
<br />N6tfpadr)
<br />,Segttentlaay Ii$tcanditione, if:.
<br />.`say, leadkag to the esuse listed
<br />. Anne events res ttingii-n'death).:,
<br />': [AST .: ..
<br />UE TO, ORAS A CONSEQUENCE OF:
<br />PA
<br />ER SIGNIFICANT. CONDITIONS -Con
<br />s contributing to the rieath but rtdt r
<br />20, IF. FEMALE;
<br />Not pregna�rt
<br />a
<br />Pragnarat-at:timaofdedtti
<br />.NeApregttattt btitiusghantwithiri42.daysofde lit
<br />Piot pregnant .bid pregnant 4S 44ya t0.1 year before death
<br />nknown i} prepbentwht in'me past year ..
<br />22d.:I NJURY':AT WORK?':..
<br />YE
<br />0
<br />'underlying cause given
<br />PART L':.
<br />21a. MANNER OF DEATH
<br />® Natural Hominids
<br />❑.Accident L..! Pendinginvestigadon
<br />0 Suicide 0 Oould not be determined
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJU
<br />2204 DESCRIBE HOW INJURY OCCURRED
<br />21b. IF TRANSPORTATION INJURY
<br />❑ 1)rveNOperator.
<br />: ❑ Peasenger _.
<br />;21Pedestrian
<br />0 Other (Specify)
<br />19. WAS•MSt)ICAL ESA.MINER
<br />0.OR GOIiQNS{R:COMTAt*TED?
<br />YEfi' NO:'...
<br />210; WAS ANAU?OPSYPERFI
<br />21d. WERE AUTOPSYi HISNGS AVAILABLE
<br />TO COMPLETLCAUBE.OF DEATH?
<br />❑.vss p NQ
<br />At barn*:farm, street, factory, office building, construction. •
<br />TION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />PATE fW DEATH (Mo.,:Dey;,Yr.)
<br />one 7202f:•
<br />23b. DATE SIGNED (Mo.,,Day, Yr.) •
<br />dune 18,>2021
<br />Tti:the bast or ttiy knowledge, death occurred at the time, date and place.i
<br />ani) due to the:tause(s) sued (Signature and Tine)
<br />Shoalb Junel :MD
<br />25 `.DID.TOBA
<br />23e. TIME OF DEATH
<br />05:04 PM
<br />USE;COt.rneeUTE TO THE DEATH?
<br />NO. '❑ PROBABLY, Q UNKNOWN
<br />STATE,
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo„
<br />•
<br />Yr.)
<br />24b. TIME OF DEA
<br />24d. TIME.
<br />LINCED DEAD: •
<br />of examination anrvoriaveatig$ton, In myeptole d9attl et
<br />date and place' and due to the eaase(s) stated. Signature sad::
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />27: NAME, T(TLE AND ATIDRESS OF'CERTIFtER (Type or Print
<br />4hoalb Z>> JuneJ;:
<br />
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