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<br />_STATE OF NEBRASKA
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<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 />
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