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<br />WHEN ;THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIRES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITAL RECORDS
<br />DATE OFISSUANCE
<br />2/26/2021.
<br />LINCOLN, NEBRASKA'
<br />1, (EE13EN7'S NAME (F„trst, Middle,
<br />Kenneth.; Atouzy Skarnlak
<br />4. CITY AND STATE OR TERRITORY, OR
<br />Loup City, Nebraska
<br />7 'SOC:9AL SE:CURIWNUMBER
<br />•
<br />507 68 0310
<br />6$4.4 t4
<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 />Suffix)
<br />FOREIGN COUNTRY OF BIRTH
<br />*AGE -Last BirStdaq
<br />(Yrs.)
<br />76
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6a. UNDER 1 DAY
<br />MOS.
<br />8s.'PLACE OF DEATH
<br />HOSE PITAL ❑ Inpatient 0 0 Nursing Wame/LTC
<br />0, ER/Outpatient E Decedent's Home
<br />0 DOA 0 Other (specify)
<br />9
<br />U
<br />v
<br />co
<br />45.
<br />F
<br />E
<br />Ik
<br />I
<br />a.
<br />8b.lACIUTY-NAME (if not Institution, give street and number)
<br />117 West 21st Street
<br />8c;CITY OR TOWN OFTlUATH (Include Zip Code)
<br />• Grand island 68801
<br />9a. RESIDENCE -STATE,
<br />Nebraska
<br />9d`.STREET !AVD NUMEE:R
<br />117 Wes0l st Street
<br />9b. COUNTY
<br />Hall
<br />DAYS
<br />HOURS
<br />MINS.
<br />3: DATE OF• ga*ra Eafl,i Bay Yr.)
<br />February S 2021:
<br />6. DATE OF elR'F#;f (Mo. Pl y,Yr•)':
<br />.hilt 1, 1944. :,;,:.
<br />10s, MARITAL STATUS AT TIME OF DEATH E; Married 0 Never Married
<br />0 Married, but separated 0 Widowed Q Divorced 0 Unknown
<br />1i<FATHERS.NAM, (Heat,
<br />Wa(31aW Skarniak
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Catherine Atkinson
<br />19, EVER IN UtS. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 06/21/1963-06/20/1969
<br />15. METHOD OF DISPOSITION
<br />E eurlai L] Donation
<br />i D Orerngtton Q Entombment
<br />Removaf ❑ Other {speelfy)
<br />l12. MOTHER'S-NAME1(First, Middle,
<br />Blanche Grabowski
<br />14a. INFORMANT -NAME
<br />Catherine Skarniak
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a,: FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apt'el Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH ISee.)nstruc
<br />16b. LICENSE NO.
<br />1448
<br />ttTa and
<br />CITY /TOWN
<br />Grand Island
<br />18. PART I. Enter the chain of events. 41sesses, injuries, or campilcatiol»fihat directly caused the death. DO NOT enter ter loss events Stich as aetdiae Wiest,
<br />respiratory arrest, or ventricular fibrillation without Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional BMs If netteasafy,
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Ureteral Cancer
<br />Y
<br />8?I.MEDIATE 09(6EIRilal
<br />tliaease orconditlon resin:..
<br />Sequentially list conditions, if
<br />any; leading to, the cause gated:
<br />on::YFne e
<br />`Eaerdia UNQ LYMfi:EAUSE
<br />(disease or Injury thnht ted
<br />the events resulting in death)..
<br />LAST _.
<br />14b. RELATtt9NSHIP Til DECEDEEtT
<br />Spouse
<br />160. DATE{Ma., Day, Yr.)
<br />February/ 11 2021
<br />STATE.
<br />Nebraska
<br />97b.:,Zip Code .
<br />68801
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the :death butnotresulting In
<br />Dilated Cardloniytipathy, Protein -calorie Malnutrition
<br />20.1f FEMALE:.
<br />Nat pregnant within past.yeer
<br />0 Pregnant of time of deatYk'
<br />Not pregnant, but pregnant within 42 days of deer
<br />❑' NM pregnant, but pregnant 49 as
<br />ye to year before death
<br />0: Unknown N Pregnant within the past year
<br />225. DATE OF;INJURY (MD., Day, Yr.)
<br />22d.INJURY AT WORK?
<br />YES .0No
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Imreetigation
<br />0 Suicide ❑ Oould not be detennined
<br />22b. TIME OF INJURY
<br />22c. PLACE OFINJU
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.: LOCATIONOFiNJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 6; 2021
<br />e underlying cause given
<br />PART'L
<br />2113. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />EPassenger
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />19. WAS IiMEOICA1 skAsuSiiiklin
<br />....
<br />OR CORONER CONTACTED?
<br />0 YES `® NO
<br />21c.WASANA
<br />YES
<br />t
<br />WERE AU BINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?'
<br />CI Q NQ.:
<br />'-At home; fame, Street, factory, office building, construction t,t
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Fabruary 11, 2021
<br />23c. TIME OF DEATH
<br />12:18 AM
<br />rad To the best of my knowledge, death occurred at the time, date and place
<br />and MOM thecause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />•r;
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2413. TIME OF DEATH
<br />PRONOUNCED DEAD;
<br />245.On the basis of examination and/or kwesligation, in my opinion t OCcurfel( - ...
<br />the tlnie, date and place and due to M e Cause(s) stated. (Signaturat d}ld:Tltlk:
<br />e
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES : NO Q. PROBABLY I) UNKNOWN
<br />3' .1,1A61t, iiiLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />4..17 Ba>�z e�t>ic
<br />260. WAS CON
<br />Not Applicable If
<br />a
<br />2813. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 24, 2021
<br />i
<br />
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