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<br />STATE OFNEBRASKA
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<br />WHEAT THIS Cil Y CJIRRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A T/2UE Ct P. 13 ThE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />F ISSUANCE'
<br />121/2422
<br />LINCOLN, NEBRASKA
<br />..
<br />8
<br />1 DECEDENT'S NAME (First, Middle,
<br />Barbara Jean Eng Fuqua
<br />202303567
<br />SARAH BOINENKAMP
<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 />4. CITY AND:STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Battle Creek, town
<br />7,B0 AL SEGUIN :NUMBER
<br />:.:1471)!M4140:
<br />8c'DPTY OR TOWN OF DEATH (include Zip Code)
<br />Gt8ilci ISland 58803
<br />9a RESIDENCE3TATE
<br />Nebraska
<br />9d STREETAND;N
<br />#9 St .lafiieg
<br />UMBER
<br />Placa
<br />9b. COUNTY
<br />Hall
<br />8a. AGE - Last Birthday
<br />(Yrs.)
<br />78,
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACEOF DEATH
<br />HOSP*TAL ❑ Inpatient
<br />0 ER/Outpatient
<br />10a MARITALAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 <F,i•ITHER'S NA.MS (Fhst, Middle, Last, Suffix)
<br />Alen Feddersorl
<br />13.:EVERIN U€$ ARMED FORCES? :Give dates of service 1f Yes.
<br />(Yes, No of Unk.) No
<br />15. METHOD OF DI$P,OSITION
<br />Bunal ❑ Donation
<br />Crenta$t tit ( E.ntonbment
<br />Removal ❑ Other (Specify)
<br />IB
<br />9c. CITY OR TOWN
<br />Grand island
<br />HOURS
<br />MINS.
<br />2216_
<br />3.DATE OF„D STH(Mo,Day'li)
<br />Novembet24,:2022
<br />6. DATE OF BIRTH (Mo., Day; Yr.)
<br />April 131944
<br />OTHER 0 Nursing Home/LTC !H
<br />p<osidea;'
<br />® Decedent's Wane
<br />0 Other (Spedty)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.,
<br />9f. ZIP CODE
<br />68803
<br />*Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Jim Fuqua
<br />12. MOTHER'S•NAME (First,
<br />Carol Benard
<br />14a. INFORMANT NAME
<br />Jim Fuqua
<br />et EMBALMER -SIGNATURE
<br />Ryan Redinger
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Kearney Cemetery
<br />17e, FUNERAL:HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />08rle11+ raatmarin-Redinger Funeral Home, 4115 Avenue N PO Bo( 2344, Kearney, Nebraska
<br />Middle,
<br />16b. LICENSE NO.
<br />1318
<br />CITY / TOWN
<br />Kearney
<br />CAUSE OF DEATH (See instriuctions and examples)
<br />18. PAR71. Ender the chain of evats--dlseaaes, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as Cardiac arrest,.
<br />'arrest, or ventricularfibrillation-without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Renal Failure
<br />Malden Surname
<br />diieass ar Sof(litian *44iiItIfl :
<br />in'6eath}
<br />$equemtaiiy Ifat'conditions, N
<br />any;k dingtothecaua0:Uated:.
<br />online e
<br />14b. RELATION
<br />SPOt
<br />18c. DAYr.):
<br />13eceintieft
<br />Nebraska
<br />i?t, Zip:cle
<br />Sg847
<br />TE IAJ
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />meet *0 death
<br />CONSEQUENCE OF:
<br />184*
<br />(diaaee or NtiilSY drat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />by
<br />18 'PARTit O: HER8*GNIFiCANT CONDITIONS -Conditions contributing to the loathput riot ren{
<br />Congestive heart failure, hypertension, atrial fibrillation
<br />(0 IF F
<br />nt 0 Not pregnant, but pregnant 48 days to 1 year before death
<br />. ❑,, thdmown E.pregnant wildn the past year
<br />pragna".c wl0rin eeerrfet
<br />(; PregAmrt at urine of death::
<br />❑> Npt txsgMsat, butpregnent within 42 days of death
<br />21a. MANNER OF DEATH
<br />Natural ❑ flonticldl
<br />❑ Accident ❑ Petjting hnV4stiganon
<br />❑ Suicide 0 Could not be determined
<br />gin the underlying cause given in
<br />22b. TIME OF INJURY
<br />21b, IF. TRANSPORTATION INJURY
<br />' ❑ Dttver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑
<br />Other (Specify)
<br />PART I. 19. WAS METHAL P EMt :
<br />P
<br />OR CONTACTS ?
<br />Q YES I NO
<br />21c. WAS AN tI+EY PRFO1kME
<br />21d. WERE AUtOPSY (FINOINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NQ
<br />22c. PLACE OF INJURY -At home; farm, street, factory, office building, construction site, (;
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />OCATION`OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 24, 2022
<br />STATE
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 28, 2022 07:00 PM
<br />,28tt alba best of my knowledge, death occurred at the time, date and place
<br />enol duo tattle demists) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEA.p:..... •
<br />•240.00 the baals of examination and/or investigation, In my opird018d ttt dcetrrred
<br /><ths tlms, date and place and due to the causes) etatetl. ( pn/{,'ggs)
<br />28. DID TOBACCO USE: CONTRIBUTE TO THE DEATH?
<br />YES BNQ a PROBABLY ® UNKNOWN
<br />27. (FAME,.TiTLB�IND.Api?1RESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand la and, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION: BEEN CONSIDERED?
<br />❑ YES NO
<br />28a. RE RAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO CI Yes
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 2, 2022
<br />
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