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<br />V TRIS COPY CARRIES THE RAISEDSEAL OF STATE OF NEBRASKA, f)"'...... "rlES THE DOCUMENT BELOW TO
<br />J1 TRUE COPY OF TRE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />H AN`SERVICES. VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOS/TOI?YFOR VITAL RECORDS
<br />MII'ITNIND P
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<br /><t.A1E0(I ISS(IAIN `E
<br />4/211
<br />LINCOLN, NEBRASKA
<br />2023042 61
<br />SA i BOHWENI AMP
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DECEDEart2.1AM5 Wit, ; Middle." Last, Suffix)
<br />try. 1AJe( Huebner
<br />ITV AND 8'1"EITE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />BOQIAI. BHOURITY iUMBER
<br />8011-
<br />0 761999
<br />rAOIU1'Y-NAME at lrniE Ins
<br />and number)
<br />BeAGE Last
<br />(Yrs.)
<br />67.
<br />Itthday Ob.owoatt 1 YEAR
<br />MOS.
<br />DAYS
<br />PLACE OF GEATh
<br />OS FriAt4iiigi Inpatient
<br />j ER�IOutpeflent
<br />❑ DOA
<br />CHI Health Nebraska Heart
<br />ft CITY oR TOWN OF DEATH lin a Zip Code)
<br />Lincoln 68526. .
<br />RESIDENTATE
<br />Nebraska
<br />. STREET AND NUMBER::..
<br />1907 W 11 th Aulrnu+E
<br />Iab. COUNTY
<br />Hall
<br />to NIAISJFAL R1 •-• AT TIME OF DEATH Married L
<br />0 Married, but separated ❑Widowed 0 Divorced
<br />Never Married
<br />❑ Unknown
<br />11. FATHER'S -NAME tars% Middle, Last, Suffix)
<br />Rodrick ">Huebnerj
<br />3 E ER IN U.S.: ARMED FORCE81t Give dates of service: if Yes.
<br />(Yes, No, or U.) No
<br />16. METHOD OF DISPOSMON
<br />Bute) ; Q(TeItifiktn
<br />trema to { Entom*ment
<br />RemovaI j'D othor(Specify)'
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />23 05158
<br />UNDER 1 DAY
<br />HOURS
<br />MINS.'
<br />3. DATE OF
<br />April 5
<br />DATE OF;
<br />Iad. COUNTY OF DEATH
<br />Lancaster
<br />S. APT. NO. 1 W. ZIP CODE
<br />68803
<br />NAME OF SPOUSE (last, Middle,
<br />Diane Kay Dzinole
<br />12. MOTHER'S.MAME (First, Middle,
<br />Mary Tarnick
<br />14a INFORMANT NAME:
<br />Diane Kay Huebner
<br />Suffix) if
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />fE G
<br />Maiden
<br />iE
<br />16b. LICENSE NO.
<br />SC
<br />left DATE (Mo..:i..Xh.)
<br />April
<br />16d CEMETERY, CREMATORY OR OT4( LOCATION',
<br />Central Nebraska Cremation Services
<br />CITY/TOWN
<br />Gibbon
<br />7a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Sheet, City or Town, State).
<br />All Faiths Frinerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OFADEAT:H:CS
<br />'U
<br />PART I. Enter dtaehitin'emote. di ne , injuries, or compiioationa.that directly caused the death. DO NOT enter
<br />respiratory wrest or ventdcuser fibrffittlion without Showing the etiology. DONOT ABBREVIATE. Enter only one cause on a line. Add additional lines If neeeseuy.'..
<br />IMMEDIATE CAUSE:
<br />"MATE CAUSE :: a) Liver Failure
<br />at examol
<br />DUE TO,; OR AS A CONSEQUENCE OF:
<br />laquentlagy get conditions, If \ b) Heart surgery
<br />fey. leading to the causatives'
<br />lin gns a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Rrsar c)Valvuler heart disease
<br />�the UNDERLYING
<br />sease er even/teat i
<br />die events reselling In
<br />LAST
<br />,OR AS A
<br />re. PART prigft
<br />!PANT
<br />NNDr71ONS.Coonditione contributing to the death but not resulting In the:underlying cause given In PART I.
<br />20. IF FEMAEE:..'.
<br />regnant,
<br />Unknown Ifpr
<br />prapthrns wittaa a¢ dayte doth
<br />gnam a3 days tai year before
<br />within the past year
<br />SATE OF iRYIMo g:I,e1y, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Monteith!'
<br />El Accident El Renting investiyetfon
<br />Suicide ❑ Couitd not be detemnined`
<br />21b.IF TRANSPORTATION INJURY
<br />Q Odvarloperator
<br />QPseanger
<br />afredestrten
<br />Other (Opacity)
<br />22b. TIME OF INJURY
<br />22c. ',LADED? INE(
<br />At hems,
<br />16.
<br />21. WAS AN
<br />[YES.
<br />t, factory, office building, construct!
<br />2211, INJURY Al'
<br />YES
<br />:1.0
<br />HOW INJURY OCCURRED
<br />r;1NJURY STRIETa NUMBER, APT.NO.
<br />(OF DEATH (Mkl., Day, Yr.)
<br />5, 2023
<br />23b. DATE SIGNED (No., Day, Yr.)
<br />Ararll 7 2023
<br />23c. TIME OF DEATH
<br />11:25 AM
<br />STATE
<br />24s. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />or knowledge, death occurred at the time, did and place
<br />enddectothe e(+) Stated. pipnetots and Tula)
<br />g Richard'B Thompson. AAD
<br />DID TOBACCO USE CONTRIBUTE TO
<br />Q YES: `0 NO Q PROBABLY El
<br />UNKNOWN
<br />T NAME, TITLE AND ADDRESS OF CERTIFY R (Type or Prin
<br />Richard BThompson, MD; 7440 S 91st St, Lincoln, Nebraska;::: 685:
<br />is of examination antler Investigation, M aur
<br />:date and place and due to the cataetl Mated.
<br />26a. NAS ORGAN OR TISSUE DONATION BEEN CONSIDER
<br />❑ YES
<br />fit N0
<br />REGISTRAR'S SIGNATURE
<br />28b. WAS CON
<br />Not Applicable If 26a M NO
<br />2$b. DATE PILED
<br />April 19, 2023
<br />is
<br />,Day, Yr.
<br />
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