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<br />STATE OF NEBRASKA
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<br />WFIEN THIS' COPY CARRIESTHE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY °FOX ORIGINAL RECORD ON FILE VVI1'1i "HE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HU MAN SERVICES,'VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF'
<br />ISS AAC,
<br />7/1-8/202
<br />LINCOLN, NEBRAS
<br />SARAH R(ilNENItA14i!'”
<br />SSISTANT STATE REGIST
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OAF. DEATH
<br />1. pECE0EN7"S•NAiNE;tFirat, Middle, Last, ` Suffix)
<br />$S1'geiit
<br />4 CITY AND STATE C R,TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebr,
<br />eb UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />Ide Zip Code)
<br />8aPLACEOFDEATM
<br />HOS,r P A , inpatient
<br />❑ EWOutpa
<br />❑ DO•A
<br />OTHER ;❑ Nursing Ho
<br />t
<br />0 Decedent's
<br />0 Other (Spec
<br />8d. COUNTY OF DEATH
<br />Adams
<br />9b. COUNTY
<br />Adams
<br />SThEET..0 rR
<br />(1; 12 ApsobeAvewe
<br />IDe, #M AR)TA£.;S"i'ATUB AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married,: but sepera act ;
<br />Widowed 0 Divorced 0 Unknown
<br />43 1fEit iN U.S ARMED' FORCES? Give dates of service It Yes.
<br />(Yes, No, or'Unk,) NO
<br />18a. EMBALMER -SIGNATURE
<br />Michael W. Tharp
<br />14a. INFORMANT NAME
<br />Ken Knehans
<br />16 METHOD OF DiSPOSITIQPI
<br />crnmatrvet;.❑ Entombment
<br />Remove( [ Other (Specify)
<br />9f. ZIP CODE
<br />68901
<br />lab. NAMEGF SPOUSE (First, Middle, Last, Suffix) if wife, giver i
<br />B01 Sargfent
<br />12, MOTHSI7'S-NAME (First, Middle, Malden Su
<br />I fttdat E'genberg
<br />18d. CEMETERY, CREMATORY OR OMR LOCATION CITY I TOWN
<br />Parkview Cemetery Hastings
<br />1Ta. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town;State)
<br />LMngstorti Butler V "hand Funeral Home, 1225 N. Elm Haetinps, Nebraska
<br />CAUSE OF DEATH (See>1nstiuctians and exarnales)
<br />Is. PART.I. Enter duo ahatnfgfevdk its eeases, Injuries, or complications -that directly caused the death. DO NOT enter tarminat events such as cardiac arrest
<br />respiratory arrest, or veX1 Sular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one fine. Add adanal lines if necessary.
<br />IMMEDIATE CAUSE:
<br />BtTBi a#tf�abi . a) Ischemic Cerebrovascular Accident
<br />$ quentailylistcordtaens..N3.
<br />any. kaufingto cannegnted
<br />•
<br />• Eilierfhe,Uf Rb1NoCAusE
<br />(dlaeaes cr injUEy #ret rpitlegtl
<br />the events resulting In darttil);::
<br />LAST
<br />1a ttART ii, o .$5R Sit Eli l
<br />t round l €#lt, L,ef .
<br />o.�O. IF,F EEMALE; .
<br />❑:Netpreunentw/#bt
<br />01'400baefd.:>
<br />tiiiWpingni(pkbufar;igliintwiatln4tdaysofdeath
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />0.Unknowniforegnatdwdthklarepast year
<br />CONDITIONS.Condition
<br />I fracture
<br />buting to the, death b rick f9stlit g lD dtetin
<br />21a. MANNER OF,DEATH
<br />® Natural ❑ t:oglktda
<br />❑ Accident ❑ iF4IttOIng Imtestiaation
<br />❑ Suicide 0 Could not be determined
<br />21b.:JF,TRANSPORTATION INJURY
<br />❑ otiarroperator
<br />pae'e"ger,
<br />LI Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AU
<br />❑YES
<br />ESCRIBE HOW INJURY OCCURRED
<br />23b. DATE SIGNED (Mo: -Day, Yr.) 23c.' TIME OF DEATH
<br />July 11 203 01:41 PM
<br />B " d Lathe meet of n(yinowledge, death occurred at the time, date and place
<br />and
<br />12 1
<br />dire to'the osusels) stated. (Signature and mie)
<br />Scott Gordon; MD
<br />24'. Q9m Lha basis of Nomination and/or investigation, in no oakum
<br />*MOON date and place end due to the eawats) skeMd.
<br />28. DID TOBAddo USE GONTRIBi1TE TO THE DEATH? 26a. HAS ORGAN
<br />�I YES ®NO IDPROBABLY 0 UNKNOWN ❑YES
<br />27 NAME, f11 ANO•ADDRESS OP CERTIFIER (Type or Print
<br />S ort Go• d ,IMPS;' 715 N Joseph Ave, Hastings, Nebraska, 88901'
<br />28a. REGISTRAR'S SIGNATURE
<br />OR TISSUE DONATION BEEN CONSID
<br />NO
<br />28b. DATE FILED BY MEG
<br />July 17, 2023
<br />
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