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<br />STATE OF NEBRASKA
<br />�rtWArAhay r x atrJfirI111Tfliissh
<br />WHEN .HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EE A IRUE
<br />copy OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN'SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISS(FANCE
<br />2/6/2023...
<br />,LINCOLN,; NEBRASKA
<br />202300688 3#.44,../1
<br />SARAH BOHNENKAMP -
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />m
<br />3
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECE04:!`1110040041104 Middle, Last, Suffix)
<br />Jerry Itlfn Cfingenpeel
<br />4. CITY AND SPATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />a:eru, Indiana
<br />CtAL SECIIRITY.NU
<br />346.1023
<br />BER
<br />8b. FACILITY -NAME (H not Institution, give street and number)
<br />4228 Norseman Ave
<br />8c :CITYOR TOWN. iF pRAm (include Zip Code)
<br />Grand ISlattd ,68803
<br />Se. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER::.
<br />4228 Norseman Ave
<br />MARITAL.STATUS
<br />Married, but sept
<br />6a. AGE - LastBirthday'
<br />(Yrs.)
<br />74:;.
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a ;PLP CE OFDEATH
<br />HOSPITAL .0 inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />T11ME OF DEATH.® Married 0 Never Married
<br />Widowed U Divorced ❑ Unknown
<br />11 FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert:.. CIInAenpeel
<br />13 EVER IN U Ji ARMED. FORCES? Give dates of service If Yes.
<br />tYak, No, or Unk.) NO..:
<br />15. METHOD OF Dt-IS-tPOSITION
<br />tJ Bonet t-1 Donation
<br />Cremeden QEntatn cent
<br />❑''Removat `:' ❑Ottte►:(Speci y)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />I. DATE OF DEATH (Mo;
<br />January 27,2023 '.
<br />6. DATE OF BIRTH (Mo., Day, v.)
<br />20, 1948
<br />OTHER 0 Nursing Home/LTC
<br />l Decedents Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />CAH
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife,
<br />Sandra L Quam
<br />9g.INS>DE iiY IJM178;:
<br />Wo
<br />112. MOTHER S -NAME (First, Middle, Maiden Surname)
<br />Catherine <E Pepple
<br />14a. INFORMANT -NAME
<br />Sandra L Clingenpeel
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1Ta,;FUNERAL HOME hiaisilE AMD MA LING ADDRESS (Street, City or Town, State)
<br />Apfet F ung a) Horne,1123 W. 2nd, Grand Island, Nebraska ;
<br />14b. RELATIONSHIP 1
<br />_Spouse
<br />18c. DATE (Mo.,;
<br />January 31.,:,
<br />CAUSE OF DEATH (See ;instructions .arid examples)
<br />M. PART L Enter the chain of events- disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />migratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a. line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />a) Amyotropic lateral sclerosis
<br />autiwATl itAit
<br />alpease or condxiatt rayu
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if ,: b)
<br />any, leading to the cause hated.
<br />online ri
<br />:'Ekertlu UNCRLYFNO cAtisB
<br />(disease or i guty>that initiated'
<br />to event resulting in death)
<br />LAST
<br />ANTAtMITHERistaNt
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE S4TERVAL
<br />ANT CONDITIONS -Conditions contributing to the death but notiresuttng':(
<br />ci
<br />41
<br />1
<br />20 IFFEMALE
<br />•Not prem wIMIn pasty;ear
<br />Uraeisotdt atMxae ctdeaas:<
<br />4.3
<br />41?1.f#egnaCll.but pregnant within 42 days of death
<br />" Mat pregnant, but pie nent.4 days to year retort death
<br />mown if pmgnaat Yaduln she past year
<br />2210DATE OF (N #URY (Mo .pay, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suic de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />teat
<br />the underlying cause given in PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />p Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />AS MEDIC40A144NER s
<br />CORONER CONTAD?
<br />YES; I I NCY
<br />21c. WAS AN AUTOPSY P
<br />❑ YES ®NO
<br />ED?
<br />21d. WERE AUTOPSY ROMS AVAILABLE':
<br />TO COMPLETE CAUSE OP. ONATN?
<br />❑YES NO ..
<br />22c. PLACE OF INJURY.At honie,:farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OF INJURY:..STREET 8, NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 27 2023
<br />CITY/TOWN..'
<br />23b. DATE SIGNED(Mo., pay, Yr.)
<br />2023 ''
<br />Fad To the best ahoy knowledge, death occurred at the time, date and place
<br />andduetotha:esuse(el stead. (Signature and 11tle)
<br />• Travis S. Hageman, MD
<br />23c. TIME OF DEATH
<br />11:20 AM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />DDE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />249. Gn the tMls of examination and/or investigation, In my opinion death ighgtrrettig
<br />the linte,..date and place and due to the cause(s) stated. (Signature surd Tide) ''
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN :O.R TISSUE. DONATION:BEEN CONSIDERED?
<br />YES NR U PROBABLY ❑. UNKNOWN ❑YES l NO
<br />2? NAM& TIT'L At bAbDRES$ OF CER1tiFiER (Type or Print
<br />Travis S;:Hagemarl; MD, 729 North, Custer Avenue, Grand island, Nebraska, 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO O YE
<br />28b. DATE FILED BY REGIS
<br />TRAR (Mo Day Yr.)
<br />February 1, 2023
<br />
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