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<br />STATE OF NEBRASKA _-___-_),
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<br />THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIP ES THE DOCUMENT BELOW TO:•
<br />A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA.: DEPARTMENT OF HEALTH AND •
<br />OMAN .VITAL ITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />]ATE OF'ISSUANO
<br />22712022 :
<br />LINCc LIV, NEBRASIC
<br />202302769
<br />SARAH BOHNENKAMY T
<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 />•PECEDENT'S•NAME (FIrMa .':Middle, ;Last, Suffix) •
<br />De inks tame& Sorge
<br />4. CITY AND STATE OR TERRITORY 'OR FOREIGN COUNTRY OF BIRTH
<br />semont, Nebrask
<br />7 SOCIALSECURiTY:NUMEER,
<br />•
<br />308-62 78;11
<br />8b. FACtli l Y NAME (If not Institution; give street and number)
<br />CMI Health: St Francis.
<br />a.l,TrYORTaIfIINQI DE4kN(
<br />C,.rantf lsiarld 66803,
<br />SetOENCE-STATE'
<br />ebraska :+
<br />9 L STREET ANP NUMMSER....':
<br />21 17 S.Rleine street`:
<br />10a• MA
<br />Ba "AGE • Last'Biiihday `6b. UNDER 1 YEAR
<br />(Yrs.)
<br />66
<br />MOS.
<br />DAYS
<br />8a. PLACE OF:PEATH •
<br />HOSP)TAL Inpatient
<br />❑ ER/Outpatient
<br />Q DOA:
<br />Bb. COUNTY
<br />Hall
<br />ITAL STATUS At'TIMME OF.D ATH ® Married 0 Never Married
<br />ried, but separated ❑ Widowed ❑' Divorced 0 Unknown
<br />11 FATHER S NAM8 (Pirst
<br />Arkhur )Nilliam Sorge
<br />13. EVER H4 U $ ARMCtt 1
<br />es No or:Unk.) No
<br />Last, Suffix)
<br />9c. CITY OR TOWN
<br />Grand;Island
<br />5
<br />2. SEX 3. DATE OF DEATH fMMa., Day Yt )
<br />Male Deoernber 16,:2022
<br />6 DATE of olfMt (ii 0,, Days, Yr k
<br />. Auguts184
<br />•
<br />OTHER 0 Nursing HomelLTC '
<br />DaS.deitt'e'Home,
<br />❑ Other (Specify) •
<br />_
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />•
<br />ISd. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />19b. NAME OF SPOUSE (First, Middle, Last
<br />i?Give dates of service if Yes.
<br />Christine Elsie Coleman
<br />12 MOTHERS -NAME (First, Middle, Maiden Stone
<br />Pauline Schwindt
<br />St ZIP CODE
<br />68801
<br />Suftln) If tylia; glee
<br />14a. INFORMANT -NAME
<br />Christine Elsie Sorge
<br />16a:-EMBALMER•SIG NATURE
<br />'. `.Not Embalmed
<br />18b. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17*. ;FUNERAL HOS E NAMME)ND MAILING ADDRESS (Street, City or Town, Statek
<br />All; Faiths uneral tome,:29'29 S.:Locust Street, Grand Island, Nebraska ,
<br />14b RELATIONSHIP TO PectiH6
<br />Sprusl9 `•
<br />16e..DATE:(MMe.;
<br />CAUSE OF DEATH '(See instructions and examples)
<br />1a. PART I. Enter Mitcham of *yenta- disaesee, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />:.: ;respiratory •t'fest-orventdatder li Satinriwitlmetshowing the etiology. DO NOT AESREVIATE.. Enter onlyone cause on a line, Add *defraud lines a necesap{y.
<br />trAmet ATE CAUSE:
<br />Nebtas
<br />17b. LIReaeoiC
<br />•
<br />IMag piAT$t%AU<#tPlnel e)Respiretory Failure.
<br />eille or condition rbaesinp, :........
<br />Sequentially dndiaens 1 ,
<br />arylJeantjigtcthe.. eUetlid.
<br />onllnoa
<br />Enter gw UNDER1 TING 0AUSE
<br />- (diaeaes or wury hist Iitkiimd.,
<br />die eventa•.resuitin9:in.death) •
<br />IE TO, OR AS A CONSEQUENCE OF:
<br />b).Severe:sepsis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />A) , Group B Streptococcal Bacteremia
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />20 IF:FEMALE
<br />trot prep ent:wlthln pant ye
<br />i'reStifktattime #1.0 )(
<br />�' Nat pregnart:bm pregnant tahhin42: days of death
<br />❑ Not pregnant .tut pregnant 43 days to t.year before death
<br />rj'�'"T ;Unknrnyn itpiagnaat witAh/ the peat ye•ar : '.'
<br />f ATE INTI
<br />(INiri b
<br />22d. INJURY AT WORK?
<br />,Yr.). -
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c..PLACE OF INJURY At
<br />22e.;DESCRIBE HOW INJURY OCCURRED
<br />22?
<br />LOCATION';OF INJURY:* STREET & NUMBER, APT.NO.
<br />23a: DATE OF DEATH.(Mo., Day, Yr.)
<br />December 16 2022
<br />• .1
<br />i-'OtWet
<br />derlying cause given in P
<br />21:0 .F TRANSPORTATION INJU
<br />biblartOperator
<br />❑ Passenger
<br />❑Pedestrian
<br />o Other (Specify)
<br />19. WAS MEttiGRUEXAMBfr)ER.::;'
<br />oR ct�IeoNt€R aoNTACTMIDa';.
<br />YES' ® NO
<br />21c..WASAN AUTOPSY.PERPOR atit.;
<br />•❑ YES1 NQ
<br />18 fi NT 01.`HE'RSIGNIFICANT.,CONDITIONS•Conditione contributing to the death but not .eau
<br />Diabetes trrorbid Obesity atr1al.
<br />. . •• , •
<br />21d. WERE AUTOPSY FINDINGS AV
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YI
<br />or5s, farm, stfeet, factory, office building, consbucti
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 19.2022.: 03:30 PM
<br />d Ta 1114 beat tit my knowledge, death occurred at the time, date and place
<br />ndduetalhecivaeIey 9Hiied:(Signature.and Title)...
<br />0 , nifer L Brown;
<br />28 DID T£IMACCO-USE CONTRIBUTE TO THE DEATH?
<br />D YES NO Q PROBABLY ' 0 UNKNOWN
<br />26a. HAS ORGAN 01
<br />❑ YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (MMo., Day, Yr.)
<br />24b. TIME OP DEAT}
<br />24d. TINE PRONOW
<br />i QEAD
<br />240.0001ebi is of examination and/or inuestlgation, in my 'oliinton4aiiiiiififufrida
<br />Dim time; date and place and due to the cawe(systided (SIgnetu$$ and Talley'
<br />TISSUE DONATION BEEN CONSIDERED?
<br />NAME, itTLE. AND ADS RES$OF. CERTIFIER (Type or Print
<br />Jennifer L. Brown; MO, 729 North Custer Avenue, Grand Islami, Nebraska, 6880;
<br />26b. WAS CONSENT GRAtl
<br />Not Applicable if 28a is:NO
<br />28b. DATE FILED BY REGISTRAR
<br />December 21, 2022
<br />
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