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<br />WEA AE J TR J771,E5 COPYdF CARP"IES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BCOPY IHR ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />tltlMAN.SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />11/29/2022
<br />RNCOLN,`NEBRASN
<br />202302650
<br />1. tSECEDENTS NAME (First, Middle,
<br />Gayle Ann Nunnenkamp
<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 />Last, Suffix)
<br />4. CITY AND STATE Oft TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />I00IAL SECURITY Nall
<br />06-64A 670
<br />ER
<br />5a.AGE - Last Birthday
<br />(Yrs.)
<br />72:::::
<br />8b. FACILITY -NAME (t# not Institution, give street and number)
<br />wo
<br />436::8, Woodland. Drive
<br />.:CITY OR; TOWN OFiIEATN (Include Zip Code),
<br />Land TslSnd 68801
<br />a. RESIDENCE -STATE
<br />Nebraska
<br />ea. Ix'PREET AND NUMBER
<br />436 S, Woodland Drive
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH .
<br />NOSPITAL 0 inpatient'
<br />Q ERIOuu patient
<br />q DOA
<br />9b. COUNTY
<br />Hall
<br />rAL ,STATUS AT,TiME OF DEATHEf Married 0 Never Married
<br />Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />FApisp.r-NA11YIE 4Firs#,,. Middle, Last, Suffix)
<br />. Ed Huebner .
<br />13. avek N US ARMf D FORCES? Give dates of service if Yes.
<br />or Unit.) NO::',
<br />95 •METHOD OF DISPOSmON
<br />( . Burlef :: ©Dtinat(on
<br />� [{Orefnagen: I rl F»rltann�3tent
<br />Q Removal ` ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH
<br />November 8 2122
<br />6. DATE OF BIRTH (Mlo„ Day; Yr j'
<br />OTHER 0 Nursing Home/LTC'
<br />E] Decedent's Hone
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />90b NAME OF SPOUSE (First, Middle, Last,
<br />Lynn Nunnenkamp
<br />12. MOTHerrs-NAME (First,
<br />Mary Belle Knox
<br />14a. INFORMANT -NAME
<br />Lynn Nunnenkamp
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16d. CEMETERY, CREMATORY OR OTHEQ LOCATION
<br />Westlawn Cemetery
<br />16b. LICENSE NO.
<br />1448
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, gib
<br />9g INSfBE C►TY UM IIS
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Grand Island
<br />FUNERAL Home NAME AND MAILING ADDRESS (Street, City or Town, State}
<br />Apfet Funeral HDme,' 1123 W. 2nd; Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions arra examples)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse'
<br />lac. DATE (Mo Day Yi }
<br />November 18,:22022
<br />eJ 14TE.....
<br />Nebraska
<br />1Ta
<br />18. PART I. Enter the Chain of events- diseases, injuries, or compllcatlonsdhat directly caused the death. DO NOT enter terminal events such as 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 />EUTA1E00SE Fina !; a) Undetermined Natural Causes.
<br />ase or canaalon yet ...... ..
<br />in
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially net conditions, if b)
<br />any. Meagln..p to me cause hated
<br />an - sass.
<br />DUE TO, OR ASAI CONSEQUENCE OF:
<br />C)
<br />APPROXMIATE4MTERVAL
<br />onset to death:. ...
<br />tMnteY:tha INDEltt«YtNt tA0.00
<br />idisea>at.or INury hat initiates"
<br />the 'events resulting In death)
<br />LAST
<br />1 18. PART II OTHER SIGNIPIDANT CONDITIONS -Conditions contributing to the death but not result(ttg tri:thp underlying cause given In PART I.
<br />Diabetes Type II
<br />IF _FEMALE•
<br />. Not pregnantwiMhtpaSt$ar
<br />❑ Ptagneti at*M. of death
<br />❑ itof pregnant, but pregniru within 42 days of de
<br />ata
<br />Not pregnant, but pregnant 43 days to 1'year before death
<br />Unknown If pragnant within the peat year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22a :DATE OF INJURY (Mitti'Dey, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES .QNO
<br />2f (OCATl9N
<br />21a. MANNER OF DEATH
<br />Natural Q HOmiCidh
<br />❑ Accident 0 Pendiirg imbstigation•
<br />❑ Suic de ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Q briverloperetor
<br />❑ Passenger
<br />•
<br />❑Pedestrian
<br />❑
<br />Other (Specify)
<br />19. WAS MEDICAL EXideetER : ;:
<br />OR CORONEM. t«f#NTACTIHD?
<br />this I ii
<br />21c. WAS AN AUTOPSYPERFORMED.
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />[3 yea ❑NO
<br />22c. PLACE OF INJURY': At home, farra, street, factory, office building, construction site, eti (S$Cifp}
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBERAPT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo Day, Yr.)
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />24d To lhM Iniatqfini8DovAedge, death occurred at the time, date and place
<br />andYdue to the abuse(,) stated. (Signature and Title)
<br />us
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />November 22, 2022
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 8. 2022
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />0 O..PfiVl
<br />00. On the baafs of examination and/orrinvestl investigation, in
<br />9 mY opinion death dttcHpt
<br />the lima.: Rate and place and due to the cause(s) started. (sIgtta ure anyi #lag}
<br />Dave Medlin, Hall County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Q YES ,i,..,:::]•:
<br />NO I❑ PROBABLY UNKNOWN ❑ YES ® NO
<br />2T, NAME, TITLE AND ADbRESS OF CERTIFIER (Type or Print
<br />Dave Medlin, Flat:County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED? :.
<br />Not Applicable if 26a is NO 13 ye.
<br />r
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 22, 2022
<br />
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