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<br />WKEN ': THIS COPY < CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES 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 OF ISSUANCE
<br />6/14/2021
<br />LINCOLN, NEBRASKA
<br />202
<br />')9.40017 8itittaket4
<br />SARAH BOHNENKAMP T ;
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1,;pECEPENT3 NAME;:(FIrst, Middle, Last, Suffix)
<br />Harr ld Victor Henry Zessin
<br />CERTIFICATE OF DEATH
<br />4.OITYAND STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Meadow Grove, Nebraska
<br />7'S6OIA4.1E0URI'rY aiikeeR
<br />iiP505432-44940!!!.,t
<br />8b. FACILITY44AME`(If not Institution, give street and number)
<br />916 E 6th Street
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />94.
<br />lib. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />8c :CI Y OR TOWN OF DEATH (Include Zip Code)
<br />•
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />94:STREET AND NUMBER
<br />916E 6th Street
<br />9b. COUNTY
<br />Hall
<br />lea. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated au Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME {First, Middle, Last, Suffix)
<br />Victor Zessin
<br />13. EVER IN UsS. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 09/09/1952-06/19/1954
<br />15.METHOD OF DISPOSITION
<br />Burial © Donation
<br />[] Cremation ©Entombment
<br />Removal ❑Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 07532
<br />3 DATE OF'DEATtt(Mo, payr Yr.)
<br />June 4:2021
<br />6. DATE OF B(RTH (Mo., ,t/ay;:
<br />November 8;:,,1926
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g, INsIDE CITY;LIMIT$
<br />YES E No
<br />ab. NAME OF SPOUSE (First, Middle, Last, Suffix) 11 wife, give maiden;/ ams
<br />Arlene Marione Stueckrath
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame); ;:
<br />I
<br />Josephine Unknown
<br />14a. INFORMANT.NAME
<br />Kathleen Marie Siemon
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16d. CEMETERY, CREMATORY OROTHER LOCATION
<br />Grand Island City Cemetery
<br />170, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />An Faiths Funerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CITY /TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examples)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE. (Mo., Day, Yr.)
<br />June 9 2021
<br />18. PART I. Enter the chain of events- -diseases, injuries,or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular tlbrl8etlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necusafy.
<br />1
<br />IMMEDIATE CAUSE:
<br />IAMEDJATECAUsE (Final a) Unknown Natural Causes
<br />dneaae or condition meaning
<br />in death) •
<br />Sequentially Hat conditions, If
<br />any,.laading tons) cause listed
<br />Ortfira a.
<br />Enter the UNDERLVINO CAUSE
<br />(disease or In)iiiy that initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE :>
<br />Nebraska
<br />17b::TJp Code:::::..
<br />68801 .
<br />APPROXIMATE INTERVAL
<br />onset Io death
<br />Mirsutes
<br />Years
<br />8. FART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but riot n
<br />20.,1F0EMALE:
<br />Nat pre9nsnt wbhln pant year;
<br />. Rue®eaili. RI:ddW of
<br />001-
<br />atitit pregrsnt, but pregnant within 42 days of death.
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknownlfpregnant:wbhin the past year
<br />220. DATE OF;tNJURY(Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES :». ❑ NQ::.
<br />21a. MANNER OF DEATH
<br />Natural 0 Homlclds
<br />0 Accident 0 Pending Investigaiii
<br />Suicide ❑ Could not be determined
<br />*siting In the underlying cause given in PART 1.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF:INJURY-A
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH(Mo., Day, Yr.)
<br />CI rY/TQGIIN :
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />tad. TP the best otduy knowledge, death occurred at the time, date and place
<br />gild due:tu:ste emends) stated. (Signature and Tide)
<br />8
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Onverioperator
<br />'j ❑ pasenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL MI:AMtNER
<br />OR CORONER CONTACTED?
<br />® YES " ❑ N0
<br />21c. WAS AN AUTOPSY PERFORMED?:
<br />❑ YES FRa NO
<br />21d. WERE AUTOPSY: FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO.:.
<br />oms, Tann, street, factory, office building, construction situ,
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />June 7, 2021
<br />24b. TIME OF DEATH
<br />Unknown
<br />{Spot ty) ;
<br />Z CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 4, 2021
<br />24d.?IME PRONOUNCED DEAD
<br />0633 AM
<br />24e.:On the basis of examination and/or Investigation, in my epinionieaih ddcurred at
<br />die time, date and place and due to the cause(s) stated. (Signature and Tide):•
<br />Matthew C. Boyle, Hall Deputy County Attomey
<br />.25.OIO TOBACCO USE CONTRIBUTE TO THEDEATH?'
<br />❑YES ;❑ NO >❑ PROBABLY ® UNKNOWN
<br />27: NAIiBE. Tung AND ADDRESS OF CERTIFIER (Type or Print
<br />Matthew C. Boyle, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is DYES. N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 9, 2021
<br />1
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