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<br />STATE 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 />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WIT) THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEiOFISSUANCE
<br />............ ....... .......
<br />11/16/2023
<br />LINCOLN, NEBRASKA
<br />202306518
<br />E
<br />:R.
<br />SARAH BOHNENKAMP
<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. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Terry Bertus Twiestmeyer
<br />4. CITY AND STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fullerton, Nebraska
<br />7 SOCIAL SECURITY NUMBER
<br />608-58-9126
<br />5a. AGE - Lask eirtha y
<br />(Yrs.)
<br />81/. FACtUTY-NAME: (If not Institution, give street and number)
<br />1803 Stagecoach Road
<br />8c. CITY t)R TOWN DF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREET AND NUMBER
<br />1803 Stagecoach Road
<br />9b. COUNTY
<br />Hall
<br />79
<br />5b.
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />tia, PLACE OF DEATH ;>
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11..FATHER'S-NAME,(First, Middle, Last, Suffix)
<br />Bertus Twiestmever
<br />13 EVER'IN U S ARMEDFORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Buda) ❑ Donation
<br />Cremation ❑ Entombment
<br />❑ Removat ❑other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 15361
<br />3. DATE OF DEATH;
<br />October 31, 2023
<br />6. DATE OF BIRTN(Mo., Day; Yr.)
<br />April 3, 1944
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g IN$IDE CITY:LIMFTS
<br />f3f' YES ❑ NO.
<br />lab. NAME OF SPOUSE (First; Middle, Last, Suffix) If wife, give maiden nems"
<br />Cheryl Norskov
<br />112, MOTHER'S -NAME (First, Middle, Maiden Sumarne)
<br />Frieda Rosendahl
<br />14a. INFORMANT -NAME
<br />Cheryl Twiestmeyer
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16b. LICENSE NO.
<br />1439
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See:: instructions and examples)
<br />18. PART I. Enteritis Chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) myocardial infarction
<br />IMMEDii0.TE CAUSE (Fihsl
<br />disease aroidkwn resulting
<br />indasth)
<br />Sequentially list conditions, if
<br />any, leading to the cauda listed
<br />on fine a.
<br />Enter the UNDERLYING CAUSE
<br />(distal* or Injury that initiated
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Thyroid Illness
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)High Blood Pressure
<br />15. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the deat
<br />ftigh OholeSterat
<br />20. IF FEMALE:
<br />❑ Nri Pregnantwigtin•
<br />pest,ysar
<br />D Prsgnam at dMa of laeuy
<br />Not Pregnant, but pr•egnant wknin 42 days of death
<br />nt, but pregnant 43 days to 1 year before death
<br />0 Not pregna
<br />0 Unknown if meanest within the past year
<br />22a.OATE OFINJURY ()Na, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />1413. RELATIONSHIP TODECEDENT<
<br />Spouse
<br />16c. DATE (Mo., Day, Yr)
<br />November 6, :2023
<br />STATE
<br />Nebraska
<br />17b ZipCode
<br />ss�ot ;
<br />APPROXIMATE INTERVAL
<br />onsefto doath
<br />Seconds
<br />onset todeath
<br />Days
<br />ut not resulting in the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />Natural ;Homicide
<br />❑ Accident Q Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF'I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY: STREET 8 NUMBER, APT.NO.
<br />0.
<br />23a. DATE'OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. Tri the batt of:My knowledge, death occurred at the time, date and place
<br />• shd due fo are tauea(s) stated. (Signature and Title)
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Ea NO ; 0 PROBABLY 0 UNKNOWN
<br />2113. IF TRANSPORTATION
<br />7 Driver/Operator
<br />0 Pettenger
<br />Q Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />onset to death
<br />Days
<br />19. WAS MEDICAL ExAMINEfi
<br />OR CORONET# CONTAt;'( D?
<br />® YES 0 N
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO '.
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />At home, fart, Street, factory, office building, construction site etc, (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />November 8, 2023
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />October 31, 2023
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />05:27 AM
<br />24e. tan the iasis of examination and/or investigation, In my opinion deatit occurred et
<br />'Me time, date and place and due to the cause(s) stated: (ai9nature and 7ttle)
<br />Benjamin W Shanahan, Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES Ea NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Benjamin W Shanahan, Deputy, County Attorney, 231 South Locust St, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE
<br />,B.r, ei, ,r., ..,:::.
<br />26b. WAS CONSENT GRANTED?:::
<br />Not Applicable if 26a is NO Q YES
<br />lJ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 13, 2023
<br />
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