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EY`1039 rlwrliDp ::•. Ti1R montm . ttwitz; ... @ ttov <br />STATE OF NEBRASKA <br />fir. -4Tomaart* <br />a, O.&,We* u I! )))D10i,06,,( e.arX,a111, <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 />