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<br />: STATE
<br />TATE OF NEBRASKA
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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, ten -AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE pF ISSUA)VOE
<br />.911112023'
<br />LINCOLN, NEBRASKA
<br />2 0 2 3 '0 6 0 3' SSA• RAH soHNENKA MPF'
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />1
<br />I. p>:CEpENDS-NAME ::(First,
<br />Eteva ,lin ()' hen
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Middle, Last, Suffix)
<br />4. GITY AND STATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Keosauqua, lowa
<br />7. $OCIALSEt(JRITY'NUM$ER
<br />480- 2-2549
<br />8b. FACILITY -NAME ((tnot Institution
<br />Mary. Lansing Healthcare
<br />ve street and number)
<br />8c: 'CITY:oft TOWN OF DEATH (Include Zip Code)
<br />.1iid--4plasttotioEitl000gp.
<br />RESIDENCE4TATE'
<br />Nebraska
<br />94STREET App NUMBER
<br />'f614 N. Kruse Ave
<br />9b. COUNTY
<br />Hall
<br />SILAGE - Last Nirthday
<br />(Yrs.)
<br />71:,
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OP DEATH
<br />DAYS
<br />HOSPITAL A Inpatient
<br />ERIOutpatient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />0 Married,` but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S4NAME;(Fist, Middle, Last, Suffix)
<br />Gilbert : Saunders
<br />13; EVER IN U ARMED' FORCES?
<br />(Yes, No, or Unk) No
<br />15 METHOD OF DISPOSITION
<br />Build `, ❑ Donation
<br />.cralfiett0iiiitiEntOtattinent
<br />Rant oval ! : ❑Other (Specify) -
<br />Give dates of service H Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DLATH(INo. Dait Yr9
<br />Septembet 10,+2023 ....'
<br />6. DATE OF `S1RTH(Mo., bay, Yr )'
<br />August 2, 1::952:;
<br />OTHER 0 Nursing Home/I.TC ❑';Hospice Fa/ality
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Adams
<br />9e. APT. NO.
<br />fob. NAME OF SPOUSE (Karst, Middle,
<br />James O'Brien
<br />14a. INFORMANT -NAME
<br />James O'Brien
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCA
<br />Central Nebraska Cremation Services
<br />12. MOTHER'S:.NAME (First,
<br />Mary Heminoer
<br />16b. LICENSE NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />YES ❑NG
<br />Suffix) If wife, give maiden name:€
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP T
<br />Spouse
<br />DECEDENT:::
<br />16c. DATE (Mo., Day. Yr.)
<br />September 11.,2023
<br />17a. FUNERAL:HOME NAME AND MAILING ADDRESS (Street, City or Town, State) :
<br />All Faittls< 'unera( Home, 2929 S. Locust Street. Grand Island, Nebraska for
<br />{>ther (Spec►j�t) �`
<br />CAUSE. OF DEATH (See lrstruotlortS:.:and ex pies)
<br />13. PART 1. Enter th6chain of events--Maeases, injuries, or complications. hat directly caused the death. DO NOT enter terminalevents 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 />plioleou 19c4.0 (Forel a) Sepsis
<br />disease or sensate)) resuWn9
<br />in deem)
<br />Sequentially list conditions, H
<br />any, leading to the cause.11sted
<br />on- M a.
<br />Enter the UNDERLYING CAUSE
<br />1dt$eeee or injury that htitiated
<br />'Sha: events result)ny In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Peritonitis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Peritional dialysis
<br />$TATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)End stage renal disease
<br />1&PART €I: OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death belt not testi
<br />Diabetes meiiitus, hypertension; peripheral vascular disease
<br />20. IF FEMALE: ,
<br />Not realiarltwigtiata8.ysar
<br />Pre9aalnet:8anaotdeatli;
<br />..❑.• Not pragnelt , but ptegnant within 42 days of death
<br />pregnant .`but.pregnant 43 day to 1 year before death
<br />0 Wnknown 11:pragnaht within the past year
<br />gin the:EinderlyIng cause given in PART I.
<br />21a. MANNER OF DEATH
<br />▪ Natural ❑ Honibdde
<br />❑ Accident 0 Pending InveatigAdOn
<br />O Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />onset IP death
<br />4 Weeks
<br />brief to death
<br />2 Years
<br />19. WAS MEDICAL EXAMINER;
<br />OR CORONER'CONTACTlD7
<br />❑ YES ®N0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NQ.`
<br />21d. WERE AUTOPSY PFINbINGS AVAILAB18
<br />To-COMPLETE.CAUSE OF DEATH?
<br />❑YES QNO
<br />22&DA
<br />OF NJUriY.(Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f. t:OCA
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, fauns, street, factory, office building, construction she, ot9. (
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY- STREET & NUMBER APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10,2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 11, 2023
<br />r. Tothe beat otmy knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Talo
<br />Susan' M Schuckert, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />02:56 AM
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES J NO 0 PROBABLY 0 UNKNOWN
<br />27= NAME,'nTLSANCTADDAESS OF CERTIFIER (Type or Print
<br />Susan M Schuckert, MD, 715 N St Joseph Ave, Hastings, Nebraska, 68198
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />LIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD '
<br />246.0n the basis of examination and/or Investigation, In my opinion tlaaut de Urred tit
<br />Sha time, date and placeand due to the causes) stated. (Signature and Me)
<br />28a. HAS ORGAN OR TiS$UE DONATION SEEN CONSIDERED?
<br />❑ YES Ea NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 1D YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2023
<br />1
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