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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<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 />DATE OFfSSUAh(C.
<br />8/14/2023
<br />LINCOLN NEBRASKA
<br />J
<br />35t4
<br />A BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR`
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />E
<br />:D.
<br />.'C.
<br />E
<br />et
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />!. DECEDENT*S.NAME .(First, Middle, Last, Suffix)
<br />Maine. Suzanne 41ostler
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR;iTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-$4-5984
<br />63.• AGE - Lett Birthday
<br />(Yrs.)
<br />65
<br />8b.`FACILrrY4NAME Of not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c.. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grant! Island 68803
<br />95. RESIDENCE-STATI
<br />Nebraska
<br />9a. STREET ANP NUMBS
<br />4513 teiSt Husker Mighway
<br />9b. COUNTY
<br />Hall
<br />um. !MARtTAL:Slams AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERS:NAME (F)rst, Middle, Last, Suffix)
<br />Raymond` Larson
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />BuHal ❑ Donation
<br />O Cremation ❑ Entombment
<br />❑Removal !': ❑other(Specify)
<br />b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />.:HOSPITAL. Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Alda
<br />HOURS
<br />MINS.
<br />2310629
<br />3. DATE OF DEATH tMo Day, Yf.)
<br />August 3, 2023
<br />6. DATE OF BIRTH (Mo., Day, Y.)`•
<br />February 20, 1958
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />Sp INSIDECrrYRIb1ITS
<br />YES :NO
<br />tab. NAME OF SPOUSE (First, ' Middle, : Last, Suffix) If wife, give maiden name
<br />Steve Hostler
<br />112. MOTHER'S -NAME (First, Middle,
<br />Carol Rakow
<br />14a. INFORMANT -NAME
<br />Steve Hostler
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />lad. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL:MOME NAME AND MAILING ADDRESS (Street, City or Town, State),,
<br />/Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska •
<br />16b. LICENSE NO.
<br />'1448
<br />CITY f TOWN
<br />Grand Island
<br />Malden Surname)
<br />14b. RELATIONSHHP TO DECEDENT:.
<br />Spouse
<br />166. DATE (Mo., Day, Yr.)
<br />August 9, 2023
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />It. PART I. Enter the chain of events- diseases, injuries, or complicatlons.Mat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, 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 />a) Sepsis
<br />IMMtffiIATE CAUSE (F(pal
<br />Mame arcondliton reifuking
<br />In death)
<br />Sequentially:list conditions, e
<br />any, feeding to the rause IIWd
<br />Enpit the UNDBRI:YINft OAtt3E>
<br />(diaaase or tact ay that tnittetgd:
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Intra-abdominal infection
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Metastatic pancreatic cancer
<br />a DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onsettOdeat(
<br />48 HOUrs
<br />onset to death
<br />48 Hours
<br />onsettotiemh'
<br />48 HotitS
<br />18 PART HI OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but
<br />acute renal (allure typa 2 myocardial infarction
<br />20. IF FEMALE:...
<br />Not pregnant within past year
<br />Pregndlttethnic efdeath::
<br />❑ Not pregnant, but pregnant within 42 days of deem
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />❑., Unknown if pregnant within the past year
<br />22a
<br />ATE OF.1IJURY (Mo..Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NQ."
<br />not resulting In the underlying cause given In PART I.
<br />21a, MANNER OF.DEATH
<br />® Natural Homicide
<br />❑ Accident ❑ pending InVaatigathyt
<br />0
<br />Suicide ❑Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE'': OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.'LOCATION 'OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 3, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Au ust.44023
<br />23d. Torp beet of my knowledge, death occurred at the time, date and place
<br />dflt due to the: csuse(s) stated. (Signature and Title).
<br />Donald R Snodgrass, MD
<br />23c. TIME OF DEATH
<br />03:31 PM
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES :: ® NO
<br />21d. WERE AUTOPSY FILINGS AVAILAB1..E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />tome, farm, street, factory, office building, construction site,
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />(SPecify):•
<br />:'ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the kiwis of examination and/or investigation, In my ophnon deegt 848red sf
<br />tine time, date and place and due to the camels) stated. (Signature and Tills)'- ..
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO ❑ PROBABLY E UNKNOWN
<br />27. NAME, 'BTU AND ADDRESS OF CERTIFIER (Type or Print
<br />Donald R Snodgrass, MD, 3533 Prairieview Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES INO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YE$; NO:
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 9, 2023
<br />
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