|
'EtG1
<br />tt1Ya,"el„
<br />11,�Ii llq��1111(t M,4 NH.
<br />11
<br />Aga
<br />111t�111I(if°fi a
<br />111,
<br />'iNA((CI`1
<br />4'114 t
<br />»��il�Idll�l'1��')%ef§9if
<br />e,1e
<br />1 •r I/III r,I,r
<br />t / //
<br />S 1f l5 Z 1
<br />/ 3 / (1 I
<br />0 11 1 C Al 11 11
<br />1 t 11 % � \ 1
<br />11 \ ( I r Z /
<br />a\ 1 � 1 1 11 11 �
<br />I /� 1 11 e 1
<br />11 r, , r I rill
<br />t er, (1 ,i .l\ e\ e e. a. 111 s33s..,.aS. eeu.ueeel./
<br />I re ,,.sari tef�si�.d .,,Q� \.,eee,ee!ln JJaAn a l e. e
<br />�)� .Jee,IN ¢e re .. (l.
<br />STATE OF NEBRASKA
<br />zd11f1111y1'tlfS�D?
<br />ir54y14fie
<br />+ 54tIIlrIAYIIA\3:... `
<br />1 rl
<br />f/
<br />Ci\ A(N Ill!/7 %-
<br />I�e.a 10� ee /; �e/
<br />,.. �, 11M1 EO
<br />APP
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE 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 OF 15$ VANCE
<br />1/2412023
<br />LINCOLN,;NEBBRA$
<br />2023©0835
<br />6
<br />w
<br />3
<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 />. DHCEPENV&-NAME (First, Middle, Last, Suffix)
<br />Roller tete Mint
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island,
<br />ka
<br />7 SOCIAL SECURITY NUMBER
<br />606-60-8836
<br />sa..AOE - Last Birthday'
<br />(Yrs.)
<br />•74
<br />8b. FACILITY -NAME (tf not Institution, give street and number)
<br />402: West 8th Street
<br />Sc. CITY OR Tosrupi DEATH (Include Zip Code)
<br />.Grantfislaild.148903
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ed STREET ANDNUMBER
<br />402 Wast 8th Stree
<br />Sb. COUNTY
<br />Hall
<br />10a. MARITAL STATUS.AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed ® Divorced 0 Unknown
<br />11. FATHER'S NAME .tFirst, Middle, Last, Suffix)
<br />Walter Smith
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 03/11/1969-04/04/1973
<br />I5 METHOD OF.. DTION
<br />:titans, : ' ]ISPOSIDo ai on
<br />El Crematlpn � Entontbm
<br />O`Removai E(ter'
<br />city)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba.IPLACE OF DEATH
<br />HOSPrrAL ❑ inpatient
<br />❑ ER/outpadent
<br /><:0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />Cif 1',
<br />23 QO54Q
<br />3. DATE OF DEATH.,
<br />Found Januar( 6,'2023
<br />6. DATE OF BIRTH (Mo.,0
<br />November 17,
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Speci r)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />i
<br />r
<br />9g INSIDE CITY LIMITS .
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. IN FO RIi'AN T -NAME
<br />Cash Minx
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'&NAME (First,Middle
<br />Yuve€ta Schlaich
<br />1$b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/ TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL:HOME NAME AND MA LING ADDRESS (Street, City or Town, State).
<br />All Faiths Pilinereffilome. 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH' (See instructions and examples)
<br />Maiden Surname)
<br />14b. RELATIONS iP TO DECEDENT
<br />Son
<br />18c. DATE 000 4:
<br />January 9; 2
<br />15. PART I. Enter the chain of events- .ateeases, kyuries, or complications -that directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAU$E(Flna a) Cardiac Arrest
<br />emus or condition resulting,;
<br />In death):........
<br />Sequentially list fond
<br />any, :Wend to the: cause
<br />on 110e a. .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) High blood pressure
<br />STATE
<br />Nebras
<br />tn. Zig:
<br />APPROXIMATE INTERVAL
<br />oneetltldenth<
<br />tmmetliate.
<br />onset to death
<br />Years
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />E,mettne iNn Ygiogause c) Hypothermia
<br />.................... ................
<br />(liaise,* MASSER& lnitietgtl
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART if, OTHER St3NIFICANT CONDITIONS -Conditions contributing to the death but not resulting kith, underlying cause given inPARTI.
<br />2D IF.FEMALE4
<br />Not pregnant Within pkat y:!.
<br />❑ Pregneet at line of 40th
<br />d
<br />Nd pregnant; but pfagaatn within 44
<br />0 Not pregnant, days of death
<br />but pregnant 43 days to 1 year before death
<br />Unknown a pregnant wahin the pest year
<br />22a. DATE pF INJURY (Mo pay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural Homicide
<br />❑ Accident 0 Reading Inves;Igstien
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Ddvsr/Operator
<br />Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />onset to;death
<br />Minutes
<br />19. WAS MEDT CA ,EXAMINER
<br />OR CORONER .CONTAC'i Et3f?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PI
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ...
<br />22c. PLACE OF INJURY -At home,;, farm, street, factory, office building, construction site, eto:(
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 IOCATiON OP IN,iUR'r -STREET & NUMBER, APT.NO.
<br />23a. DATE OFDEATH (Mo:. Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />2
<br />B {tad. Toths beet of my'knovledge, death occurred at the time, date and place
<br />o f +p!$:five,.01As wuse(s) stated. (Signature and Title)
<br />E '' Ir
<br />a -
<br />23c. TIME OF DEATH
<br />2s. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES No:;....13 PROBABLY ] UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 9, 2023
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />January 6. 2023
<br />ZIP,
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />01:33 PM
<br />x48.On the basis of examination and/or investigation, in my opinion MattOsp ureti4
<br />Ito tithe, date and place and due to the cause(s) stated. (Signature anomie)
<br />Christopher J Harroun. Hall County Attorney
<br />28a. HAS ORGAN: CR TISSUE, DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />3T• N 4MkmilifiAt40ADORESS OF CERTIFIER (Type or Print
<br />Christopher) Harroun, Hall County Attorney, 231 S Locust St:,Grand island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />a 4 7
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO YE9
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.
<br />January 19, 2023
<br />
|