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<br />WHEN 110SCOPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT GERTIRES THE DOCUMENT BELOW
<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 />)ATE OFISSiIANCE
<br />7/14/2023
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKA
<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, DECEDENDSNAME (First, Middle; Last, Suffix)
<br />Richard I!ter I(.00l Jr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />8c Cf iY OR TOWN OF DEATH {include Zip Code)8d, COUNTY OF DEATH
<br />Grand (stand 68803I Hall
<br />Se. RESIDENCE-STATE9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d. s'rRl«i8T AI <T NUNIBERi:
<br />42.3 Spur.Ln
<br />180. If.MARITAL STATUS ATTIME'Op DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed '❑ Divorced 0 Unknown
<br />11 PATHEdt S•NAME (Pkat Middle, Last. Suffix)
<br />Richard .. KDoI Sr
<br />1J )r 13. EVER (N UJB ARMED FORCES? Give dates of service N Yea.
<br />(Yes,No, or Unw) Yes 01/15/1!:3-01/13/1967
<br />8. METHOD OF DISPOSITION'.
<br />>Slrr)al
<br />1 J CenladDanfton
<br />ron❑ f] Entombment
<br />[�<Rattwvaj ❑ OtTtsr (spec ar)
<br />10b NAME OF;SPOUSE (Fiala, Middle, Last, Suffix) If wife, give malthmit
<br />Bonnie Kuehler
<br />12. MOTHER'&NAME (First, Middle, Maiden
<br />Delores Hegge
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />18d. CEMETERY, CREMATORY OR 0
<br />Westlawn Cemetery
<br />175. FUNERAL' HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Air: Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska:::....
<br />CAUSE OF DEATH! (See:#nstruct)t na a)id examoIes)
<br />IL PART t: Enter the chain: of events. -diseases, Injuries, or compllcations.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricularttbdaation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tines If necessary.
<br />IMMEDIATE CAUSE: .
<br />a) metastatic melanoma
<br />IMMEDIATE CAUSE WI
<br />n
<br />diabase or condition tes
<br />in death)
<br />DUE TOr OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to thecause listed
<br />on WOE.DUE TO, OR AS A CONSEQUENCE OF:
<br />EnlertheUNQEfiLYE/QCAUSE c)
<br />Idbeaseor injarYtbntlfftoted!
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resuNitig in the t derlying cause given In PART I.
<br />, IF FEMALE:
<br />g�-� tetpregnantvAhktpastyear
<br />I--{ P�regnantat of death :;
<br />Nat ptagnerd but ptspeluiF wMdn 42 days of death
<br />❑ Not pragnard;but pregnant 4$ stays to 't year before d
<br />❑ Unknown If pregnant Within the past year
<br />21a. MANNER OF. DEATH
<br />Natural - ❑ Nomlaide
<br />❑ Accident ❑ Pending Investigetirlit
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />2111, IF TRANSPORTATION INJURY
<br />CrldarfOperator
<br />passenger
<br />p.Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY A( holt*, farm, street, factory, office building, co
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />?S ❑YES 0 N
<br />r 22f L#1CAiTONbit! NJURY .STREETS NUMBER, APT.NO. CITWITON STATE
<br />23a. DATE OF DEATH '(Mo., -Day, Yr.)
<br />July 6, 2Q23
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />441$.4023 13;42 -AM
<br />tad. To:the beat 0f myknowledge, death occurred at the time, date and piece
<br />and due to lhecresasaj stated. (Signature and Title)
<br />Ryan Ramaekers, MD
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />4al of examination antler I
<br />he, date and place and due to the oauae(si
<br />8. DID TOBACCO USE CONTRIBUTE TO :THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION
<br />YES ttij NO ❑ PROBABLY 0 UNKNOWN ❑ YES 11NO
<br />NAME,'TITLE; ND4100 S OF CERTIFIER (Type or Print
<br />Ryan Rantaeker&,. MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68503'
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY MEGISTRAR1
<br />July 11, 2023
<br />
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