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<br />STATE OF NEBRASKA
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<br />THIS COPYCARRIES THE RAISED SEAL OF STATE QF NEBRASKA, IT CERTIFIES THE;DOCUMENT BELOW TO
<br />ATRUE COPY OF T.,HE ORIGINAL RECORD ON FILE WITH:THE HE NEBRASKA DEPARTMENT OF HEALTH AND
<br />MAN=SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPoOSITORYFOR VITAL RECORDS
<br />;miiV1Y(i1%
<br />DATE OFISSUA CE
<br />7/1'1/2023
<br />LINCOLN, NEBRASKA
<br />202303614
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Julius Reinhold Doehling
<br />4Ws( AND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Ulysses, Nebraska
<br />1. SOCIAL SECURITY NUMBER
<br />606-36-0131
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />Grand Island Lakeview Care & Rehabilitation Center
<br />Se. AGE - Last Birthday.
<br />(Yrs.)
<br />8c.: ITYOR TOWN (IFBATH (Include Zlp Code)
<br />'Ork)(114:',Islopcki$8801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Sd. STREET AND NtUMBER
<br />1506 W2Louise
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />92
<br />6a, Pt,ACEOF DEATH
<br />HOSPITAL ❑;Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a :MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER S -NAME (First, Middle, Last, Suffix)
<br />Emil DOehhn(a
<br />13 :EVER iN US ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />3. DATE OF DEATH(Mo., D1ty.Tr,)
<br />June 24, 2023
<br />6. DATE OF BIR'hH(Mo., Day;Yt.)
<br />MINS.
<br />November 4„1930
<br />930
<br />OTHER IE Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />tie. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Bg.IN CITYLIMnI's
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donna Yocum Jonak
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) :
<br />Maria Rathien
<br />14a. INFORMANT -NAME
<br />Donna Doehlinq
<br />14b. RELATIONSHIP TO DECEDENT`
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />) Burial El Donation
<br />1 E
<br />Crerasaon ❑ ntombment
<br />Removal ❑Other (specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />lab. LICENSE NO.
<br />16c. DATE (Mo., tray,
<br />June 27,.2023`
<br />STATE
<br />Nebraska
<br />17a. FUNERAL:HOME.NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska-
<br />CAUSE
<br />ebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART L Enter the chain of events- .diseases, Injuries, or complicatlonadhet directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory sweet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUSE(vpd '> a) Respiratory Failure
<br />disease recondition sesuhiug
<br />Sequentially list condition, If
<br />any, leading to the cause listed
<br />orkaa .... ...
<br />Esto the1INDSskire4GCAUSE
<br />(disease or hyiuythat Itdaated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Diabetes Mellitus
<br />171e. Zip Coda
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />onset to teeth
<br />Months
<br />onset: 0 death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />16 PART II .: ER S(Gi FICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hosptce and.died at facility
<br />onset to death
<br />19. WAS MEDiCAf miasma
<br />OR concea8R CONTACTED?
<br />❑ YES ®N0
<br />20.1E FEMALE,:.
<br />Nbt pregnanf:wlthH pain year
<br />.1:1Pnvioioolkootdoouc,
<br />NetPregaatd butpra5rlantwidBn 42 days of death
<br />❑ '.Not Pregnant, but pregnant 43 days to year before death
<br />❑ ,Unknown ifpregnant witlhin the past year
<br />21a. MANNER OF DEATH
<br />® Natural El Homicide
<br />❑ Accident ❑ Ponding Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Dolver/Operator
<br />.. Pµsenger
<br />:I] Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS .AVAILA E
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES EI NO
<br />22a. DATE OFlNJUI
<br />(Mo:, Day. Yr.)(
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spec(*)
<br />22d. INJURY Al` WORK?
<br />El YES NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />NJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Jtlne 24, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 27. 2023 05:30 PM
<br />20. Toa he hast of rtfy knowledge, death occurred at the time, date and place
<br />Unit due to the'cause(s) stated. (Signature and Title) ---
<br />Midiael A. Donner, MD
<br />MID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO• ,,.❑ PROBABLY KJ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />244. TIME PRONOUNCED DEAD
<br />24e.:G5 **bowls of examination and/or Investigation, In my opinion death ri rrai'et
<br />`the time, date and place and due to the causes) stated (Signature a l't10e)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES NO
<br />27 NAME, TIME: ANO ADDRESS OF CERTIFIER (Type or Print)
<br />iMichael Donner, MD, 729 North Custer Avenue, Grand Island,
<br />ebraska,68803"
<br />26b. WAS CONSENT GRANTED?:.;.
<br />Not Applicable if 265 Is NO ❑
<br />In NO
<br />28b. DATE FkED BY REGISTRAR (Mo, Day, Yr.) I
<br />July 10, 2023
<br />
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