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- • •
<br />ph< STATE OF NEBRASKA
<br />1461110?„.,,,,,vrAwmizrlwaysonon.;:wa.pt.,a2tenvotr,!;;;;;:.,,,v?momm.,,
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<br />WHEN THIS OPV CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOIAITO
<br />BEA TRUE COPY OP 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 />: • ..
<br />•
<br />LINCOLN, NEBRASKA •
<br />• • •••-• ••
<br />• •
<br />-46
<br />43
<br />202302800
<br />SARAH BOHNENKAMP' 7. • ...
<br />ASSISTANT STATE REGISTRAR.. • .
<br />DEPARTMENT OF HEALTH •
<br />AND HUMAN SERVICES • •
<br />• •
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH 23 06914
<br />11,..I3ROODENT'LEA(AMEOFIt':OL :Middle Last, Suffix)
<br />4:ciTyANtsl.A.TE•0S10izstrosie., OR FOREIGN COUNTRY OF BIRTH
<br />• •••••:: - •
<br />...:.::Bridgepok.Nebraske . •
<br />t,:scic!A4:.,ssopeiTwN14111BEa .
<br />-024632HOSPITAL
<br />8bt FACILITy-NAME(ltiint institution, give street and number)
<br />.;••• •• ; : .• • ••• r
<br />(WAGE LifitilfittlidaY::
<br />(Yrs)
<br />80
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF:DEATH •••••::
<br />Inpatient
<br />•
<br />• I:3 ER/Ou patient
<br />• 0 DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEV11040
<br />May.22,'2O3•
<br />6. DATE OF earraiteim,
<br />October 21.,,1942.: •
<br />• : : ••
<br />OTHER [-J Nursing Home/LTC •RHospioe:paotoy
<br />0 Decedent's Home • • :
<br />RI Other (Specify)ASilSTED LIVING
<br />Sc CITY OR tOikot.OgA1H-(inoltide Zip Code)
<br />Grand Island 88803
<br />ga. RESIDENCE -STATE ••
<br />Nebraska
<br />1920 Sa9ewood Avenue
<br />Sb. COUNTY
<br />Hall
<br />40it•AloSTALArrot-mATToe Of •DEATH 0 Married 0 Never Married
<br />0 Married, but sepatated: Widowed 0 DIvorted 0 Unknown
<br />•. • . .
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />• • •• •:•,•• • :::
<br />10b.: NAME:OP:SPOUSE (Fit- Middle, La
<br />• • John Schieno
<br />Of. ZIP CODE
<br />68803
<br />SedfigGEG51,"IdEllTk:
<br />•s jJN0M!
<br />Suffix) if wife, give maiden name
<br />• •• • • • •• •
<br />•
<br />•
<br />11. FATHERs.NASE;Ftlst, .....Middle, Last, Suffixf
<br />Carl::-'0#04010*Otir:GI:H.Offeit:,. •
<br />••
<br />13 0:011.1*Aaiiiisp:::FOOES7 Give dates of service if Yes.
<br />(Yes, No, or uilii4No : •
<br />I.:12. MOTHERNAME (First, Middle,
<br />Pauline :, Pearl Reimers
<br />Maiden Su ame)
<br />14a. INFORMANT -NAME
<br />Sadie Knapp
<br />I...10700.
<br />•
<br />• • 13•Rietieviii,Medtliii'(divicify). •
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />16b. LICENSE NO.
<br />1537
<br />CITY/TOWN
<br />Grand Island
<br />lia.:FdeigtiAL.,:k.divig•INANg.ANdM*II,ING*DDRESS (Street, City or ToWnState):::,. •
<br />n''../.44)feEdi102:i.14di'd0.V:•EI Grand Island, Nebraska ••
<br />CAUSE OF DEATH (See'inEteuCtiOnS and examples)
<br />iti. FART I. Enter the itidin of *yenta. -disealies; injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />•:'.....'
<br />respiratory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />.:::... • IMMEDIATE CAUSE: :: - :::••• . :::: .:... : ..: .•:::. • •• • ,.....•
<br />fitit500iATEOtidttkiFinlif:i • ..0•-'. IN VaiCular dementia
<br />. : .
<br />::.niot.0:01.'',04000044164::::.:..,.. • „
<br />*n.In .d" • • '•••: • ; • ' bOB TO OR AS A CONSEQUENCE OF:
<br />iIeguaritielly Sat tenditione;
<br />:l" I5dlflgioth #pc! .
<br />DUE TO OR AS A CONSEQUENCE OFEitt4rSheUNDER).YINGCMISE C):
<br />•••••• " • n' ••• •
<br />(d(setbe Injury
<br />Inditited: • •••••• ' •
<br />the4Yents.resusinoln Fes"): • •:
<br />P...To,Ort.AS A CONSEQUENCE OF:
<br />LAST d)
<br />•*".' - • •
<br />8 FART ii OTHER SIGNIFIPARTOONDMONS-Condfilons contributing to the death but not resulting in the Underlying cause given In PART L
<br />20. IF •••:- T: •
<br />*0..005 flt•tfitlini,Plnie'''• • •
<br />11r. • •
<br />,5iitmitwithln4Z days Of
<br />43.••
<br />O Not pregnant, but pregnant
<br />•:::;•:.D..yInISnn.'!„.ai days to 1 Yeat
<br />past year
<br />•,.
<br />22d. INJURY AT WORK?
<br />El YES ONO
<br />death •
<br />before death
<br />21s, MANNER OF:261p ]:
<br />Natural
<br />o Accident 0 Pe
<br />ittit g in
<br />0 Suiciddetermined
<br />22b. TIME OF INJURY
<br />140: kgukt5p10101toOkOkOW
<br />-Daughter- : • • •• •
<br />. Sc:
<br />• ima.3.0;*.2023gia:
<br />Nebraska
<br />88801
<br />APPROXIMATE INTERVAL...
<br />onset t.doeSt:'•
<br />• • '; •
<br />onset to death' •••• ' .
<br />• onset hili.itiefit*
<br />• ,
<br />•
<br />• ...*oili3i10.4431408
<br />••
<br />19. WAS MED100;0400*f
<br />' OR CORONERAOHTACTeD,
<br />DYES. • :NO . ' • ••
<br />21c, WAS AN 'AUTOPSY PERFORMED.t::
<br />0 yes •••• :JR!:
<br />NO
<br />216:: IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />.] . Pedestrian
<br />e Could not be
<br />0 Other (Specify)
<br />22c PLACE OF IhUUiY.At home fitrtn, *treat, factory, office building, construction 'tilts; .•
<br />• ••i• ••,••;••••:•;•-: • • ••:••• • ••••113ir •
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />12Lit...OcATIOM.OFINdoRr: STREET & NUMBER, APT NO . • .
<br />•.•
<br />22d..DATEDF DEATH (Mo., Day, Yr.)
<br />5.AB1i22,:20.2
<br />230,,OATR.S!oNEDIER0Day, Yr.)M23202 •
<br />a.
<br />' CITYITIOIAIN:;•:•••
<br />23c. TIME OF DEATH
<br />04:40 AM
<br />TRISttlweeef 'ay:IInov.1°41gs death occurred at the time, date and piece
<br />arid due lotuS cease(s) stated (Signature and Thiel
<br />• .
<br />Travia:S...Haoenian, MD..
<br />25. DICL•TOBACCO•USE CONTRIBUTE TO THE DEATH?
<br />j YES NO Q,.,PROBABLY : UNKNOWN
<br />STATE •
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />• TO COMPLETE CAUSE OF DEATH?
<br />0 YES DM0 •
<br />• 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />••••••••••••
<br />•-. • •-i••••••••.,
<br />24b. TIME OF DEATH
<br />atop
<br />24d. TIME'PRONOUNCED DEAD ••••• •
<br />SeS Ottthe beeis of examination and/or investigation, in my opinion Outfit eceunred #;:;:' •
<br />theithea,:ilate and place and due to the Cause(s) stated. (Signature and Title) • ::;;
<br />. . . . .
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />NANIEJITIA'Ai‘iiiiADDR508 OFCERTIFIER (Type or Print
<br />. „
<br />ravit S.ilabeineii,. MD, 729 North Custer Avenue, Grand Island, Nebriake,!:68803::'
<br />280,.. REGISTRAR'S SIGNATURE:.
<br />.62
<br />26b. WAS coNSENT•GRNmp?
<br />Not Applicable if 28i is NO tYES •
<br />I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) ' •
<br />May 23, 2023. : : •
<br />
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