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<br />WHEN< THIS > :COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, • IT •
<br />CERTIFIES THE DOCUMENT BELOW TO BR '<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 O ISSUANCE
<br />4/12/2019
<br />LINCOLN NEBRASKA
<br />••
<br />RUSSELL FOSLER
<br />202302227 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />- ;AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT` OF; HEALTH;AND HUMAN SERVICES
<br />CERTIFICATE <OF3EATH"
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Keith Richard Rolls
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Leroy, Nebraska
<br />SOCIAL SECURITY NUMBER
<br />::508-4:00.1938
<br />54AGE: Leat..: hday
<br />8ot.
<br />N. UNDEi:.A.YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 22019
<br />8a. PLACE OF DEATH
<br />HOSPITAL © inpatient 2LWSlt 0 Nursing Home/LTC
<br />ERROutpatent 0 Decadentre
<br />O other (SP
<br />FAGIUTY•NAISE (If not Ilte tltutlon, give street Snd nu
<br />CHI Health St. Frank s
<br />8c. CITY OR TOWN OF DEATH (Include Zip
<br />:Grand::, Isla nd : 68803
<br />8a RESIDENCEtaTATE
<br />Nebraska s .. ....... .
<br />STREET AND NUMBER
<br />715 W John St
<br />9b. COUNTY
<br />Hall
<br />90. CETf:OR "TOWN;::
<br />Grand:tSIand
<br />ed. 60 TY OF DEAR
<br />I Hall
<br />FacEity
<br />9e. APT. NO.
<br />9L ZIP CODE
<br />68801,
<br />sal CITY UMflI
<br />® YES ❑ NO
<br />1 s. MARITAL STATUS AT. TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Kenneth Rolls
<br />1©b. NAME OF.SPOUSE'(FI et, ::Middle, Last, Suffix) if wife
<br />Gtadys R >Karr
<br />I12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Vera Mohlman
<br />13.: EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No,. or tom) No
<br />14a. INFORMANT -NAME; :.,
<br />Gladys .Rolls
<br />14b. RELATIONS$IP.TO oessoENT;:
<br />Wife
<br />15. METHOD OFEIISPt)SIT'ION
<br />® Burial :.❑ Donation
<br />0 Cremation 0 Entombment
<br />aRemovai 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16b'LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER, LOCATION.
<br />Cedarview Cemetery
<br />7a. FUNERAL H.pME NAME AND MA LING ADDRESS (Street, City or Town, Stileel'
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska'
<br />CITY / TOWN
<br />Doniphan
<br />CAUSE OF DEATH (See rnstructionkand examples)
<br />1s PART 1 Enter Rig Phalli et events- •diseases, Injuries, or c*mpgeations.that directly caused ia-:00ath AO NOT enter temiinel events such aa camas arrest,
<br />fgsplraiory arrear or f ennriculer fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cense fin a line.!Add addhlenal lines If necesse
<br />IMMEDIATE CAUSE
<br />IMMEDIATE CAUSE (Final
<br />a) Sudden Cardiac Death
<br />disease o, condition resulting
<br />En death)• :;;;DUE TO, OR AS A CONSEQUENCE OF:',
<br />erpiehtlallyfatconditions, a :; b)Ventricular Fibrillation
<br />•teadmg tb the cause Reeve
<br />18c. DATE (Mo., DaY
<br />(rr,)
<br />April 8, 2019
<br />17b riP:Go&
<br />68801 •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the. UNDERLYING CAUSE C)
<br />(d s._....i ..hat Initiated #�ss�Ssiorinjury:liatinitfaatd`;; -
<br />'She exams reetsdeyflt dealt" DUE TO, OR AS A CONSEQUENCE OF:
<br />tAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />.. IF`FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnent at time of death
<br />Nps tdaQnarlr bbd ptagnaFtt,within 42 days of death
<br />❑. Not pregnant but prilgnniN A:3 days to 1 year before death
<br />ij ikrrdtyn Kgt gnantelttiln the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not bedeteitetned
<br />21b B. TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />0 pedestrian
<br />9nterl8paciry)
<br />onset to death
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTAC rEI ..1
<br />•
<br />21c. WAS AN AUTOPSY :I RFORMED?
<br />❑ YES ®No
<br />21d. WERE AUTOPSY FIND)NGS AVAILABLE
<br />TO COMPLETE CAUSE:OP 6.411tT..
<br />❑ YEs C] NC
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d.;INJURY AT'WORK?
<br />22b. TIME
<br />92e. DESCRIBE HO
<br />LOCATION OF INJURY • STREET & NUMBER, A
<br />200' 6ATE t DEATH (Mei., Day, Yr.
<br />23b. ran SIGNED (Mo., Day, Yr.)
<br />URY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />URY OCCURRED
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and.due to the cause(s) stated. (Signature and Title)
<br />24a. DATE SIGNED
<br />Afit %2011 •
<br />STATE
<br />Yr.I'
<br />24b. valeOF DEATH
<br />(c7:45 PAR
<br />TIME I lt0140 INI+x.ED
<br />07:4,PM
<br />24e. On the basis of examination and/or investigation, In my optsaon deat)t ooccened at
<br />the time, date and place and due to the cause(s) stated, (8lgnssire and This)
<br />Willamette Gallagher, County Attorney
<br />Ac. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 2. 201 9
<br />5. DID Tf3BACCCI USE:: ;+ .IBUTE TO THE DEATH? 26a. HAS ORGANOR TISSUE,DONAlloweeffl CONSIDERED?
<br />0 YES 0 NO 0 PROBABLY to UNKNOWN 0 YES ] NO Not Applicable if 28a kr NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print'
<br />WirffiRTIftiPs31431t1Ef, County Attorney, 231 S Locust Street, Grand island Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />,ar
<br />28b. DATE FILED BY REGISTRARiiiMitnDay Yr) ...::;
<br />April 8, 2019 .
<br />
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