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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELO
<br />BE A TRUE CQPYOF 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 R leggy -lie
<br />12/1$/2023
<br />LINCOLN, NEBRASKA
<br />p
<br />dr
<br />la>
<br />202306764!
<br />304
<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 />1. DECEDEN NRME:i(First, Middle, Last, Suffix)
<br />Cheryl ?:K Harder
<br />CERTIFICATE OF DEATH
<br />4. are AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings„ Nebraska
<br />1.3OCIA1- $EcuarryUMBfR
<br />60646-49'41
<br />5L AGE -Last @IrthdaY
<br />(Yrs.)
<br />8bi'FACILITYNAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />8c'C(TY QR TFiWN OF.DEATH (Include Zip Code)
<br />Grand Island 88803
<br />9a.`RESIDENCE-STATE
<br />Nebraska
<br />REET.A 4o NUMBER
<br />3941 )UIr ry Ln
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE,OP
<br />DEATH
<br />HOSPITAL I Mp4Uent
<br />0 ER/OU patient
<br />DOA
<br />10a.. MARITAL STATUS AT TIME OF DEATH 1 Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11 FATHER'S -NAME l
<br />llvin Kurt:.
<br />13. EVER IN U.S ARMED
<br />(fes, NO, Or Unk.) No
<br />15. METNOD OF DISPOSITION
<br />Sadat IE3P0O tion
<br />Cremat(ot1 ❑ Entonnbment
<br />Removal; ' ❑Other (Specify)'
<br />Give dates of service N Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OP f3PJiTH potpkpawyoli
<br />December $, 2023
<br />OTHER 0 Nursing HomeILT
<br />❑ iDecedent's
<br />❑ Other (Specify
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />INSIDE r tTY UMfTS
<br />I `YES `N O
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, g(e
<br />Dennis Wayne Harder
<br />112 MOTHER'S -NAME (First, Middle, Malden Sumett�
<br />Mareilene Ebel
<br />14a. INFORMANT.NAME
<br />Dennis Wayne Harder
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.FUNERA. HOME NAME AND MAILING ADDRESS (Street, CItyr or Town,:State)
<br />l) Faiths Puneral Home, 2929 S. Locust Street, Grand Island;: Nebraska
<br />18b. LICENSE NO.
<br />CITY 1 TOWN
<br />Gibbon
<br />14b. RELATIONSHIP Tt7 DECEE3DLNT'
<br />Spouse
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART!. Enter the chain of events- -diseases, injuries, or tompdcat(ons.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory *nest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />s+a rF a) Cardio respiratory failure
<br />EDIA0
<br />CMtSB root
<br />egsgiase er condition resuelnjj
<br />in peathi
<br />8equemialty list tondltioM, if
<br />any, leading to the cause listed
<br />gniide a.
<br />8idtrrthe UNOEAt.YINt¢
<br />(dleeae0 or Ynjury!1hd Ea
<br />the events Mau
<br />LAST
<br />ng in C
<br />6AU55
<br />eWed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) brain herniation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) intracranial hemorrhage
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8 ;PART 11 OTHER SIG.M(FICANT CONDITIONS -Conditions contributing tothe
<br />breast dancer
<br />20 IF FEMALE:
<br />�ii Notpregnitnwahktpast:year
<br />Pregnentat #Ime df dao .
<br />❑ Not pregnant, but pregnant walla 42 days of death
<br />❑.. Not pregnant, but pregnant 4adays to:1 year before death
<br />❑,.
<br />,Noltnownglivearntof within the past year
<br />22dJDATE OF (NJUI
<br />(Mo x Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />ath but not reari
<br />21a. MANNER:O.F DEATH
<br />Natural ❑ Hankadahtv
<br />0•
<br />Accident ❑ Pending estgetien ..,,
<br />0Suicide
<br />0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t LOCATION OF INJURY • STREEL & NUMBER, APT.NO.
<br />43:
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />December 8, 2023
<br />CITYI QWN
<br />fn the underlying cause given In PART 1.
<br />21b. IF TRANSPORTATION INJURY
<br />© DtlVar/Operator
<br />❑ Pasiienger
<br />Pedestrian
<br />0 Other (Specify)
<br />19. WAS Mari
<br />OR GORON
<br />❑ YES
<br />21d. WERE AUTQPSYFINDINGS AiTAI4
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑..
<br />F INJURYAthornd ; fern, street, factory, office building, construe
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 12,2023
<br />23e. TIME OF DEATH
<br />01:54 AM
<br />Tp the I bast Of my knowledge,death occurred at the time, date and place
<br />*iatddetotbeaause(s) Mated (Signature and Title)
<br />25. Dip TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YSS ]NO ❑ PROBABLY ❑ UNKNOWN
<br />2T NM E; TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />>+ + + Nebraska,
<br />STATE
<br />ZIP CGDE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEATH
<br />24d. I1ME PRONOUNCE!) 1
<br />24e. On the Mals of examination and/or investigation, In,my opinton lfeeth+
<br />;3111 time, date end place and due to the causes) stated. ISigiisi)ua
<br />28a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />❑YES 1N0
<br />tD
<br />28b. WAS CONSENTGRANrfli€D?
<br />Not Applicable If 28a le NO ❑ YrES
<br />0
<br />28b. DATE FILED BY REGISTRAR
<br />December 16, 2023
<br />
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