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<br />!!!!1.1#.00.144 THIS ;:`!COPT • CARRIES THE ' RAISED SEAL OF THE STATE ' OF NEBRASKA, 'IT
<br />=' CERTIFIES THE DOCUMENT BELOW TO OSHA TRI ' COPY OF THE ORIGINAL RECORD
<br />DN FILE • WITH : THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE fF:SSUANCE` RUSSELL FOSLER
<br />4/12/2019 20230.2221 ASSISTANT STATE REGISTRAR RAR
<br />•
<br />LJNCOLN, NEBR;4SKq DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OFHEA)4H;AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Keith Richard Rolls
<br />4 CITY{YNt? STA: I) Oft'1` HNITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Leroy, Nebraska .
<br />{s 7. SOCIAL SECURITY NUMBER
<br />iia 508-401938
<br />e Sb FACILI1 Y?NAME of Aot Institution, give street and number)
<br />CHi. Health Sit Fr ndis
<br />Sc. CiTY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island:. 68803
<br />9e' RESIDENCE-S1ATE
<br />Nebraska
<br />9d. STREET ANO NUMBER
<br />4' 715 W John St
<br />9b. COUNTY
<br />Hall
<br />sa AGE LastStithday
<br />80
<br />6tI. UNDER I YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />.;;MOS...
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2, 2019
<br />6. DATE OF B RYN (Mtn., I3®y Xr ),
<br />July 1, 1938
<br />Sc, PLACE OF DEATH
<br />HOSPITAL ©, Inpatient OTHER 0 Nursing Homsll.TC 0 Hospice FaCSity
<br />:ER/Outpatient 0 Decedent's Nome
<br />DOA • 0other i y).
<br />&GCITV.D OWN:.
<br />Grandiskand'
<br />did. COUNTY QF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZiP CODE
<br />68801
<br />9g. INSIDE Cfl I'Mrrs'
<br />M YES D NO
<br />ITUB AT Tun OF DEATH ®D
<br />separated;; 0 Widowed
<br />Married Never Married 0 Divorced 0
<br />11. FATHER'S -NAME (Fiist, Middle,
<br />Kenneth Rolls
<br />13:EVER IN U S.: ARMED FORCES? Give dates Of service if Yes.
<br />(Yes No. cr Unlc) NQ
<br />Unknown
<br />NAME OF,`SPOUSE (FiXSE, ;Middle, Last, Suffix) If wife, give maiden nasus
<br />Gtedys R t ::Karr
<br />Last, Suffix) i' 12 MOTHEti$=NAME (First, Middle, Maiden Surname)
<br />Vera Mohlman
<br />u y5 mgrapDOFtaaPb51 .N
<br />5 ® Burial D Donation
<br />0 Cremation 0 Entombment
<br />1-1
<br />a"t D I3etriovai D ortatoOpecify)
<br />14a. INFORMANT -NAME
<br />Gladys Rolls
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />1915. LICENSE NO.
<br />1495
<br />CITY I TOWN
<br />Doniphan
<br />i17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)'.
<br />g All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />G " disease is sonctiur, reeNiR:ng
<br />CAUSE OF DEATH (See instructions anck examoles)
<br />to PART I F_ntef tlta'dlaitt df events --diseases, hRuhes, or complkations4hat directly cauMidilss deagt. t10 Nor enter temdnsI eser is such as cardiac arrest,
<br />resplrafdryearreati or:vamHerilar titxatation without showing the etiology. DO NOT ABBREVIATE. Enter oily doe Oise #m a ere:: Add additional lines if necessary.
<br />IMMEDI
<br />ATE CAUSE
<br />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death
<br />di
<br />any. teatu
<br />on line a.
<br />.Ender the. UNDERLYSMO CAUSE
<br />(disease orisgvry hatindlttted
<br />pie 4 4,1 r¢stdtl(kg in deathi
<br />:DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />14b. RELATK)N$H P,TO DECANT::.
<br />Wife
<br />16c. DATE '(Md. I %Yr.
<br />April 8, 2019
<br />STATE
<br />Hebra
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset til
<br />18. PART II. OTHER SIGNIFICANT CONDITiONS-Conditions contributing to the death but not resulting ki the underlying cause given In PART I.
<br />.IFF€MALE.
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />�: t p�egnant; but ptegnatlt within 42 days of death.
<br />3'tat pregnant,.tndt peegnadt.4t days to 1 pier before death
<br />D uslinewn x prgpnsdt MMtii the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d.:lNJURY AT WORIt'T''
<br />DYtcS DNt
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident D Pending Investigation
<br />D Suicide 0 Could WV be doterained
<br />22b. TIME OF INJURY
<br />212i IF:.TRANSPORTATION
<br />D DrivedOperator
<br />0 Passenger
<br />D Pedestrian
<br />D OlherfSpecify)
<br />INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTE0? :.
<br />® YES
<br />21c. WAS AN AU7OPSVPFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?.
<br />DYES ❑NO•
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Speciiy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />i5'
<br />.9
<br />a
<br />F¥I` DEATH (Mo., Day, Yr.) •
<br />236. DATE StGNEO (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />and due to the cause(d) stated. (Signature and Title)
<br />6. DID TOBACCO USE.O:UNTRIBUTE TO THE DEATH?
<br />0 YES D NO 0 PROBABLY ® UNKNOWN
<br />• 27. NAME, TiTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />11i)ltainette Gallagher, County Attorney, 231 S Locust Street, Gram
<br />STATE ZIP CODE
<br />. DATE SIGNED (Mo.. Day. Yr.} 24b. TIME OF DEATH
<br />A8111-572019" O�r45 PM
<br />2,4e. PRONOUNCED DEAD (Mo., Day, Yr.y 246. TIME PRONOUNCED
<br />April 2. 2019 07:4y'rI,.PM
<br />24e. On the basis of exarektallon anchor Investigation, In my oplaiop dept occurred at
<br />•
<br />the time, date and place and due to the cause(s) stated. (Signal* and Tftls)
<br />Will mstte Gallagher, County Attorney
<br />26a. HAS ORGAN OR TISSUBUONA`TION BEEN CONSIDERED?' 2$b. WAS CONSENT GRANTia07:
<br />D YES 51NO Not Applicable If 266 Ia NO D YES 0 NO
<br />3d. To tiro best of my knowledge, death occurred at the time, date end place
<br />SIGNATURE
<br />F Nebraska, 68801
<br />28b. DATE FiLED BY REGISTRA
<br />April 8, 2019
<br />81440117, Yf.)
<br />
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