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<br /></\ STATE OF NEBRASKA ::.
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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASIG4,1T CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />DATE OF ISSUANCE
<br />5/12/2023
<br />LINCOLN, NEBRASKA
<br />nded
<br />202302783
<br />3,414atil &kW/
<br />SARAH 13OHNENKAMP
<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 />1.4SCEDENT8-,NAt (First, Middle, Last, Suffix)
<br />ttax Alterl Bachman
<br />4 CITY AND$TATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Chappell, Nebraska
<br />7.<S0CIAL S ERITY'NUMBER
<br />•
<br />505.7ti 87'58
<br />5a AGE - Last Birthday
<br />(Yrs.)
<br />IBb: FACILITY -NAME tff riot Institution, give street and number)
<br />aE 4119 Cannon Road
<br />ec CITY OR TOyuN OF DEATH (Include Zip Code)
<br />' :rand lsiat'id 88803
<br />1 Se. RESIDENCE -STATE
<br />Nebraska
<br />9d STREET AND NUMBER
<br />4'� 19 Cannon Road
<br />9b. COUNTY
<br />hall
<br />70.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑';Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />1OYa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />e 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />II..:FATHER'S•NAME(First, Middle, 'Last,
<br />(AlBachman
<br />13. EVER fN U.S, ARMED FORCES?
<br />(Yes, No, or Unk.) NO
<br />18..r MtETHOD;OF DISPOSITION
<br />• t J Burial ❑ Doli*tlon
<br />Cremattor# ©:Entombment
<br />Remo+raP ?! ❑ other(Specify)
<br />It
<br />Suffix)
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS. "'-
<br />23 04996
<br />3. DATE OF DEATH (Mo., Day Yr.)
<br />April 2, 20;3
<br />8. DATE OF BIRTH (Mo. DayrYr
<br />August 6,«1952:.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />hall
<br />9e. APT. NO.
<br />9f. ZIP CODE .
<br />68803
<br />t iitr
<br />98• )NSIDe
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Melanie Kaliff
<br />14a. INFORMANT -NAME
<br />Melanie Bachman
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)';
<br />Helen Schmidt
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILINGADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CITY I TOWN
<br />Gibbon
<br />;kyIMtTS`:
<br />14b. RELATIONSHIP TO°Emmer'
<br />Wife
<br />16c. DATE (Mo., Day, Yr.).
<br />April 4.2t#2&
<br />CAUSE OF DEATH (Sea instrpctiane and examples)
<br />1a. PART I. Enter the chain of events- -diseases, injuries, or complicationsihat 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 it necessary.
<br />IMMEDIATE CAUSE:
<br />8ehipo1ATec*us9 (Rena) a) Myocardial Infarction
<br />disease et 4onditton tmeuh)nd .. .
<br />h
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />the omsg ,YiNo CAIN
<br />(disease bt hbJary:that ktfttifted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:.
<br />c)
<br />STATE
<br />Nebraska
<br />17b. Ztp Code
<br />ai;18801:0:
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />; 18. PART 1i O n CR SIGNIFICANT CONDITIONS -Conditions contributing to the death t but noresutNng:in Mee underlying cause given in PART I.
<br />iAs€hrna, Part reastis, Prostate Cancer, Hypertension, COVID-19
<br />D. IF FEMALE:
<br />Not pregesnt within past.ye,
<br />' Pregnantat time of death;
<br />❑:, Natptagi: , but tprepllant within 42 days of death
<br />Not pregeisnt, but pregna443 days to:1 year before death
<br />Unknown if."pregnpn(whfirt tM peat gear
<br />( 22a.DATfx OF;.NJURy (Mo Day, Yr.)
<br />22d. INJURY.AT WORK?
<br />❑YES ❑NO
<br />21a. MANNER OF DEATH
<br />Natural 8 Hotnieide
<br />❑ Accident Pendinglnvestlgeson
<br />0 Suic de ❑ Could not be determined.
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other(Specify)
<br />19. WAS MSD1CAL EXAMINER
<br />OR CORONEN' CONTACTtib?.
<br />OYES ❑ NO
<br />21o,.WAS AN AUTOPSY PERFORMS
<br />YES NO
<br />21d. WERE AUTOPSY P..DINGS AVA1LAIdLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES L NO .
<br />22c. PLACE OF INJURY -At home,. farm, street, factory, office building, construction site. etc. ($peter)
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />122( LOCATIONWF INJURY STREET & NUMBER, APT.NO.
<br />•
<br />230. HATE OF i)gaH (Mo., Day,Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />Irl To the beat of my knowledge, death occurred at thetime, date and place
<br />and due teihe rause(s) stated. (Signature and Title)
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?r
<br />YES ❑ NO ❑ PROBABLY' UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 4, 2023
<br />24b. TIME OF DEATH
<br />Unknown
<br />Zip CODE ;
<br />11 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />ADril 2, 2023 09:55 AP
<br />34a Cn the basis of examination andlor investigation, In my opinion, -sawed at
<br />:ata lane, date and place and due to the causes) stated. (signature ala)
<br />Matthew C. Boyle, Hall Deputy County Attorney
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ]NO
<br />NAME -TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Matthew C. Boyle, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />128a. REGISTRAR'S SIGNATURE ?
<br />tern 18 Part 2, Add "Covid-19"
<br />8.411-01-ictoth4:64-24
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 17, 2023
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