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jaainig °EIlNllliitnRwtliNge6Z20111il14llyi)!Y$ <br />_STATE OF NEBRASKA <br />s •816tH}.tdJ�+.,;c,�s§�.4499)'t'rt'C14�D2 s� zaY <br />�wuaa�aa <br />q Yt/Wi9Itf994faitr. .z <br />t)a.Vd));((Ariii <br />xdlwN THIS care tHE RA/SED SEAL OF STATE OF NEBRASKA, 11` CERTIFIES THE DOCUMENT BELOW T <br />E A 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 />AZO Of ISSUANCE <br />6/22/2023.. • <br />NCOLN, NEBRASKJ <br />NTIS NAME (First .'•: <br />V r artt'td Day; <br />202302724 <br />SARAH BOH TENKAMP '. <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 />2. SEX <br />Male <br />3. DATEOfDEATH (Md., D <br />May 10 2023 <br />AND. STATE OR TERRITORY; OR FOREIGN COUNTRY OF BiRTH <br />• <br />.n:! Island: Nebraska <br />00iAL $Et<I RITY NIS S@ER <br />457 V-4606 <br />8c. C)TY OR TOWN•OF DEAT (Include zip Code) • <br />Grand Island 68803 <br />9a )iESiDENCE STATE <br />Nebraska :. • <br />9b. COUNTY <br />Hall <br />5a. AGE LaSttirthd <br />(Yrs ) <br />63; <br />SbUNi ER 1 YEAR <br />Sc. UNDER 1 DAY <br />MOS. <br />DAYS <br />8a. PLACE OF DEATH ' <br />HOSPITAL ] Irypatient <br />ERIOu patient <br />❑ DOA <br />9c. CITY OR TOWN <br />Grand Island <br />HOURS <br />MINS, : <br />6. DATE'OF EIRTH(Mo.; bay, y.r4 <br />December .9.5; ,1959 .. <br />OTHER 0 Nursing Hoene/LTC, <br />0 Decedents Home <br />® Other (Specify)ASS) <br />8d. COUNTY OF DEATH <br />Hall <br />Be. APT. NO. <br />9f. ZIP CODE <br />68803 <br />fiii:::MOITALATATOSATilMBIDi DEATH ® Married 0 Never Married <br />0' Married;: but separated ❑ Widowed ; 0 bivorced 0 Unknown <br />11 PATHSR'S: IME :(Ft <br />Rolland Calvin <br />13 EVERINUS.ARME) <br />Brea, N0', or-Unk.). <br />16: METHOD OPDISPOSItION <br />!'0.4114.* <br />Qi3oitatfo[t'; . <br />ORCES <br />Suffix) <br />top, NAME OF'BPOUSE (trtrst,' Middle, Last, Suffix) If wifs, give mail(( <br />Katherin JoAnn Schroeder <br />Give dates of service If Yes. <br />8tI INSIDE CITY AMtfS <br />YES [:.Nis <br />1 <br />12 MOTHER'&NAME (First, Middle, Maiden'Sumame) <br />Norms Jean' Henderson <br />14a. INFORMANT -NAME:' <br />Katherin JoAnn Day <br />16a. EMBALMER•SIGNATURE <br />Not Embalmed <br />16d. CEMETERY; CREMATORY OR OTHER LOCATION <br />Central Nebraska Cremation Services <br />170 FUNERAL HOME NAMOND MAILING ADDRESS (Street, City or Town, State) <br />AH Faiths iineral ome,:2929'S. Locust. Street, Grand Island, Nebraska.;. <br />CAUSE OF DEAT}I(See'i <br />16b. LICENSE NO. <br />CITY / TOWN <br />Gibbon <br />14b. RELA'tiONSHIP TO DEC <br />Spouse <br />16c DATE <br />May.: 12, <br />y, Yr.} <br />Ad examples) <br />10. PART 1..Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />; or venhfcular fibnlfation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: <br />a)Non :.Hodgkin's Lymphoma <br />0.cantgti <br />,the. cant <br />DU <br />f, OR AS A CONSEQUENCE OF: <br />APP <br />tinset'tti.:deaer <br />;' :18 Mantle <br />XIMATE INTERVAL <br />BtffSfinet]NpPr)!4LYMlfi OJ;4151 <br />dis¢98a tSr fah/II/AS• tnitiBited <br />1te: •••••• dee <br />PI. <br />re <br />dt} <br />UE TO, OR AS A CONSEQUENCE OF: <br />18„PARTIi;' <br />ER SIGN(I ICANT CONDITIONS -Conditions contributing to the death <br />EMALE. <br />it Pia -,000,41.#!se <br />giro df death.::: <br />but yraiieYant within 42 dfys 01 death <br />t41'41ye to 1 year before death <br />iNJURY:ATWO <br />;,:❑YES <br />21a. MANNER OF DEATH <br />® Natural ©Homicide <br />❑ Accident Q•Pending faysst,ga#ion <br />suicide Could not be determined <br />Heti residting n th®underiying cause given in PART I. <br />22b. TIME OF INJURY <br />22c. PLACEOF INJURY JAt <br />220. DESCRIBE.HOw INJURY, OCCURRED <br />28a.I3 TE OF"DEATH (Mo., Day,Yr.) <br />May 1 O, 2023 <br />23b. DATE SIGNED(Mo.; Day, Yr,,) 23c. TIME OF DEATH <br />•itilllay 12 203 01:55 AM <br />Topp.o hast of my knowledge, death occurred at the time, date and place <br />Chtt*RO PSP Sais) stated (Signature and Title) <br />ry Settle, M <br />21b.,IF TRANSPORTATION INJURY <br />© Dttuer/Operator <br />'O Passenger <br />t Pedestrian <br />0 Other (Specify) <br />19; WAS ME(DICAt EXAMINER <br />• OR CORON4:R0ONrACTEDI <br />• 0••YE§• .`:. <br />21c. WAS.AN:AUTOPSY PE.RF.ORMEDP <br />O YES Ix NO <br />21d. WERE AUTOPSYF(NDINGS AVA€LA64E <br />TO CO(iApLETE:CAOSE;OF DEATH? - • <br />YES=: <br />ime'farm, street, factory, office building, construction <br />STATE <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24c. PRONOUNCED DEAD (Mo,; Day, Yr.y <br />24b. TUNE <br />DEA <br />24d. TIME PRONOUNCED DEAD <br />244.00 the basis of examination and/or Investigation, in my opinion dsaatpacum <br />• the time; date and place and due to the_cauae(e) stated: (6tgnsita'e and"i.Nlei• <br />• <br />35?D O TOBACCO USE CONTRIBUTE TO THE DEATH? <br />YES P40 ❑ PROBABLY 0 UNKNOWN. <br />NAME,'ifTLND ADDRESS Oh�CEAtTIFIER (Type or Print <br />nary Settje,,Mb, •21,16 W Faidley #400; Box 9802, Grand Istand, Nebraska, 888(13 <br />260. HAS ORGAN. OR TISSUE DONATION BEEN CONSIDERED? <br />❑YES JNO <br />26b. WAS CONSENT GRANTED?: <br />Not Applicable if 26a la NO YES: <br />28b. DATE FILED' BY REGISTRAR <br />May 18,2023 <br />0.;.Day, Yr.) <br />i <br />