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<br />STATE OF NEBRASKA
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<br />NowEN 7'MS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH nie NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN svivoss, virAL RECORDS OFFICE,;, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />AArE OF ISSUANCE
<br />7/14/2023
<br />LINCOLN, NEBRA$lfE
<br />202303884
<br />SARAH BO
<br />ASSISTANT STATE REGIS'
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />8
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DECtir7ENT$NAME (Ellet, Middle,
<br />i t8t10n KBK# ori
<br />4. CITY AND STATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Suffix)
<br />CERTIFICATE OF DEATH
<br />Sherman County, Nebraska
<br />SOCIAL SECURITY 1U MER
<br />800-38-7051:
<br />Mi. MAClLITY-NAME (If.ttot Instltutmn, give
<br />Tabitha At P6aire Commons
<br />Sa. AGE Last Biiday;;
<br />(Yrs.)
<br />8a:P
<br />.HOS
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nurs
<br />❑ pace
<br />® Othee(SpecUy)AS$I
<br />3. DATE -OP
<br />July 3, 20
<br />8. DATE OPMTH (Ma., Day,:
<br />1.
<br />8c. CffY OR TOWN OF DEATH (Include Zip Code)
<br />Grind island 88803
<br />9a RESIDENCE4TAT
<br />Nebraska
<br />TRLer ANO NUMBER:
<br />4152 feet 12d>..
<br />10a MARITAL STATUS AT;TIME OF DEATH 0 Married 0 Never Married
<br />❑Married, but separated Widowed 0 Divorced 0 Unknown:
<br />9b. COUNTY
<br />Hall
<br />1. FATHER S-NQ,ME {First Middle, Last, Suffix)
<br />Genn Ke:nYOfl
<br />13. EVER II1 U S;:ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />:Bcutfi © Donatlan
<br />[ rematton Q$ntombment
<br />❑ Ftsrinoval : Q
<br />other(specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />lib NAME OF: SPOUSE (Fir#,•
<br />Carol Hummel
<br />12. MOTHSI
<br />Anda
<br />14a. INFORMANT -NAME
<br />Debra Petermann
<br />16a. EMBALMER -SIGNATURE
<br />Stacie [ Cook
<br />18d. CEME ERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Horne, 2929 S. Locust Street, Grand Island, Nebraska
<br />6e. APT. NO.
<br />Middle, Last,
<br />9f. ZIP CODE;'
<br />68803
<br />(turns) if wife, give maiden nanatf
<br />!$•AIAME (First, Middle, Mai
<br />Wei83
<br />18b. LICENSE NO.
<br />1495
<br />14b. RELA ION&Nllp TO til
<br />Da.
<br />18c. DATE: (mo, PitY. '1(r.)
<br />July 11., ... .
<br />CITY (TOWN
<br />Grand island
<br />CAUSE OF DEATi4ASeCinstetictteinaand excartates)
<br />IL. PART C Enter the chain of OYents- diseases, injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory anent, or vemdcuhv fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />tate nATfr traf Ii btM . „... a) bradycardia
<br />disO ice or GQAd4l*fl reMtlsn9:....
<br />:Cede
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />list conditions, n., b)second degree atrioventricular block
<br />to the cause ttsted
<br />DUE TO, OR AS A CONSEQUENCE OF:esteem 040%00840V a)
<br />`>
<br />(di seasaattnlurYatet!MidOted..
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST. ` d) \..
<br />OI
<br />18 PI RT 11 OTIrER S GNIFICANT CONDITIONS -Conditions contributing to the death bul noli ultil Irl the Underlying cause given in PART 1.
<br />gastroitibestit l hemottbage, Diabetes, chronic kidney disease, history Of 8 cerebrovascuiaelaccident
<br />20 IF FEMALE
<br />'INot preglantwl Wa pmst.year
<br />Fregntntattlmeofdatdt:;
<br />I 'Net Pregnant, but pregnant wltbiM 42 days of death
<br />❑ Nin pregnant, but pregnam 43 days to 1 year before d
<br />Unknown If pregnantwithin the past year
<br />age DATE OF IN JURY (Mec, bay, Yr.)
<br />AT WORk?:;
<br />YES ❑ NO
<br />228 tocATIDN:t'I�FINJ
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending InvesBgatiei
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OFF INJURY"
<br />SCRIBE HOW INJURY OCCURRED
<br />RY : STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 3, 2023
<br />23b. DATE SIGNED (Mo., DayYr.)
<br />,Jliti 10 .21123
<br />24d. Tat* haat at my knowledge. death occurred at the time, date and pace
<br />audible to Mem:Weis) stated. (Signature and Tine)
<br />Travis S. Hageman, MD
<br />21b, IF TRANSPORTATION INJU
<br />© Driver/Operator
<br />E"1 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />OR
<br />0
<br />0. WAS AN
<br />❑TES(
<br />21d. WERE AU"
<br />TO COM
<br />❑ YES
<br />home, farm, skeet, factory, office bufltflng, construction
<br />cITYITOWN
<br />23c. TIME OF DEATH
<br />09:45 PM
<br />STATE
<br />241. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />E4e On the Might of examination tion andlor investigation, In my epbdon death:1130MMak
<br />the time, date and place and due to the causes) stated. (Signature and TlN:d) ....
<br />24b. WOEOF
<br />2 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES NO PROBABLY ❑UNKNOWN' 0 YES El NO
<br />27 NAME,11 .: o ADDRESS OF CERTIFIER (Type or Print
<br />t'av13 S. 14agernaii, MD, 729 North Custer Avenue, Grand Island, Nebraska,68803
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />8b. WAS CONSENT
<br />Not Applicable If 28a M
<br />28b. DATE FILED BY REGISTRAR (Me, Day, Yr.)
<br />July 1.1, 2023
<br />
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