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<br />tIv(t�aN\ STATE OF NEBRASKA ),
<br />: effelRffflNt"'
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA ItCERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH ME NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES,. VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA 7E OP ISSUANCE
<br />b72l�023 '
<br />LINCOLN, NEBRASKA
<br />202302782
<br />3011
<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 />[1, DECEDENTS-UAME (First, Middle, Last, Suffix)
<br />IIII Owen Eimer .. KilgOre
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Salina, Kansas
<br />SOCIAL SECURITY..NUMBER
<br />506.164 770,
<br />5s AGE Last 51 day . UNDER 1 YEAR
<br />(We.) MOS.
<br />100
<br />o� 8b. FACILITY -NAME Moat institution, give street and number)
<br />108 Cleveland. Street
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HDA SPTAL © inpatient
<br />8c ciTY OR TOWN OF DEATH (Include Zip Code)
<br />Grand (slarid 68803
<br />ERIOu patient
<br />DOA
<br />2 8a. RESIDENCE•STATE
<br />Nebraska
<br />9d. STREETANDNUMBER
<br />108 Cleveland Street
<br />10a. MARITAL STATUSATTIME OF DEATH ta Married 0 Never Married
<br />es 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME (FitRt,.
<br />Elrrner Kilgore
<br />t 13. EVER IN U S. ARMED(FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 1941-1945
<br />18a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />Middle, Last,
<br />9b. COUNTY
<br />Hall
<br />Suffix)
<br />U
<br />to
<br />EntarttteUNDERLYE4O CAuSt#
<br />(diaeaa dr i fury that initteted
<br />16. METHOD OF DISPOSITION
<br />® ❑ Doltatign
<br />0
<br />Cremadou Q Entombment
<br />"Removal :: C] Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mirk, Day. YT )
<br />April 22, 2023
<br />6. DATE OF BIRTHImo.,
<br />November 22,1::922
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />90. INIIt cm i. MITk
<br />xis; rio 'i
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Kim Sundara
<br />14a. INFORMANT -NAME:
<br />Kim Kilgore
<br />12. MOTHER S.NAME (First,
<br />M€nni8 Lambert
<br />16d, CEMETERY, CREMATORY OR OTHER: LOCATION
<br />Greenwood Cemetery
<br />18b. LICENSE NO.
<br />1439
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Lhtlnoston.Sondermann Funeral Home, 601 N. Webb Road, Grand Island Nebraska
<br />fiddle,
<br />CITY / TOWN
<br />York
<br />CAUSE OF DEATH (See InstructIonS and examples)
<br />Maiden Surname)
<br />14b. RELATIONS TO DECEDENT
<br />ScOUSe.
<br />18c. DATE'(Ma.,.Day,yr.)
<br />April 26, 2023
<br />1a. PART L Enter the chain of events•. diseases, Injuries, or complications -that 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 one line. Add additional lines if necessary. ,4
<br />IMMEDIATE CAUSE:
<br />adM CilaTisc uss(Fioal a) Respiratory Failure
<br />diseSes or eaaditiO t resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, if b) Chronic obstructive pulmonary disease
<br />any, leading to the cause listed
<br />On gas:}. .. ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />7 LAST
<br />d),
<br />STATE a:
<br />Nebraska
<br />17E, ZfCode
<br />68803 ,
<br />APPROXIMATE INTERVAL
<br />18. PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />Chronic Itidneydisease, history of gun shot wounds to abdomen
<br />0, IF FEMALE:..;
<br />❑ Notpregnentwininpastyear
<br />❑ Pre gnantatiaofdeath
<br />❑ Not pregnant, tiutpregant;tlehin42days ottlaetir:
<br />A0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If pregnantwi hm the past year
<br />22a. DATE QF INJURY(Mc.,'Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Nbmicide
<br />❑ Accident ❑ Peding Invs$dgaii¢a
<br />0 suicide ❑ could not be deter fined
<br />ultbtg in Ute underlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY -STREET & NUMBER, APT.NO.
<br />d
<br />73 k
<br />d c
<br />5
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 22, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ao Il 26, 2023
<br />23d. fie dile best of my knowledge, death occurred et the time, date and place
<br />entitle tei the eause(s) stated. (Signature and Title)
<br />Jennifer L Brown, MD
<br />21b. IF TRANSPORTATION INJURY
<br />00,4r/Operator
<br />pabNnger
<br />Q Petustdan
<br />❑ Other (Specify)
<br />to d
<br />< 1 Day .;
<br />onset ttpdeath<-:
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />URY.Ai home, farm, street, factory, office building, construction site, etc;
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:05 AM
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES iii NO ❑PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />ZIP WOE
<br />DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />4e Ort the basis of examination ander investigation, in my opinion death aattitre4 /
<br />• tba time, date and place and due to the cause(s) stated. (Signature riatfifit
<br />28a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />2f. NAME.TITLE AND AppRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD; 729 North Custer Avenue, Grand Island, Neb
<br />ska, 68803.
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ] YEE'
<br />❑ NO .
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 27, 2023
<br />CEJ
<br />tri0
<br />0
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