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, �ttrao/n� STATE OF NEBRASKA
<br />„l//1llfifll1110, * P.WO ITiair* �,1gi'ilp, r41)7:11tINIJJs?:;,
<br />WHEN THIS Copy CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OP 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 />LIANCE
<br />f/1 )2023
<br />LINCOLN, NEBRASKA
<br />202400652
<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 OFDEATH
<br />y'. DECEOEarrso taalcltst, Middle, Last, Suffix)
<br />D ugtas ':!„ester ::,Codner
<br />4.CITY Mb STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney,'Nebraska::.
<br />7. SOCIAL SECURE
<br />506-024262
<br />NUMBER
<br />Sa. AGE • Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (if Sot Institution, give street and number) ,
<br />1315 011V .treat : ;.
<br />CITY OR TOWN OF DEATH (include Zip Code)
<br />Wood 68883'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d S'FRELTANDNUMBEit;;:.
<br />131$ Ull�t'street
<br />10a. NARr7AL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />i1 FATHER'S -NAME tFItik MidcSe, Last, Suffix)
<br />Charlestt)bert Codner
<br />13. EVER IN U'S ARME1'FORCES? Give dates of service If Yes.
<br />(Yes, No, or Ink.) Yes 05/22/1968-02/24/1970
<br />Itt METHOD OE- DFSSOS.1.TION
<br />ri I Bur(al isCl OOntitlon
<br />L„i.�t+remai(r)il' O entombment
<br />❑Removal i�DtUer(Specify)
<br />74 .;
<br />No. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />sat.§PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />9c. CITY OR TOWN
<br />Wood::#iver
<br />HOURS
<br />MINS.
<br />22::00021.
<br />3. DATE OF DEATH ;(1Y1s.,
<br />January 3, 2023
<br />9. DATE OF aIRTl1(rida., Days
<br />Seot mbeit>8y.1 8
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />Sc
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />16b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give Maiden netiii
<br />Karen June Allan _
<br />12. MOTHER'S*NAME (First, Middle, Maiden
<br />Luetta Mae Dubbs
<br />14a. INFORMANT -NAME
<br />Karen June Codner
<br />lila. EMBALMER -SIGNATURE
<br />Chris McCov
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />x7a..FUf fBRAL HOME NAME•AND MAIUNG ADDRESS (Street, City or Ton, State)
<br />r
<br />Afel Fune al Hume 112 w
<br />3 W. 2nd, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />is. PART it Enter the chatn of events- •disleses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respihrtery area, orventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add eddabnal lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) End stage congestive heart failure, chronic Combined systolic diastolic congestive heart
<br />failure
<br />IMMEIIIATE QAU8E 1Flnitt
<br />dte444arep/x4i)4 raiulthtg:
<br />In reedy...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sesuentingkstcenalaons,lr cardiovascular disease
<br />arnii 40014 totn. OiosHow
<br />Enteoiek::tiNDER('I
<br />.idiseeH'dr b lury that
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />le f*RTrI:O'h 1 R SIGNIFICANT CONDITIONS•Condlt)ons contributing to the death but not:rbsaltin g In theunderlying cause given in PART I.
<br />Type l disbetes, chitinio kidney disease stage IV, hypertension, cerebrovascular disease
<br />2f) IF FEMALE
<br />Not plsg,wnt kAdNn taut eau
<br />ptegnerrt at tltae 4f death
<br />© Not pregnlrM; aur pteerant within 42 days of death
<br />❑ Not pregnant, but pregnsnt 43 daye to t year before daath
<br />Q
<br />IJnknoymkp tae wltMest kw Past Year
<br />22a,1ATB Oi IIURY (Mo: #)ay, Yr.)
<br />22d. INJURY AT WORK?
<br />YES :.:O, N°;::::.':a:
<br />21a. MANNER OF DEATH
<br />® Natural 0 Himicide
<br />❑ Accident 0 pending Invpnlgat(bn
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />216 ►F TRANSPORTATION INJURY
<br />D Drlyar/Operator
<br />OPassenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />,IDE CITY UMTS
<br />YES NO
<br />14b. RELATION5Htp TO DEICE) NT`
<br />18c. DATE (ice, Days Yr.
<br />January
<br />Nebraska.
<br />1T►: Ri)r:C4Ctv:;<
<br />88801
<br />•
<br />INTERVAL
<br />olaetitl:id
<br />3.4 Years
<br />ofkeet is death
<br />>10 Years.,,
<br />1t. WAS YED)CAL'ExAirlileER:: ;?
<br />OR' CORONER' CONTACTED?
<br />❑ YES : tin NO
<br />tic. WAS AN AUTOPSY: PEItf
<br />YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO CC:AM IT CAUSE OF DEATH?
<br />22c. PLACE; OF INJURY At home, farm, street, factory, office building, co
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2140CATIOICOF ETA NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />January 3, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 3,<2023
<br />cITY/TOWN
<br />23c. TIME OF DEATH
<br />10:25 AM
<br />,To the Wet of on knowledge, death occurred et the time, date and piece
<br />atrai dueto:tti tau?MAW.
<br />es(s) I ' W . (Signature and Title)
<br />Steven Husen, MD'
<br />23. DID TOBACC©USE CONTRIBUTE TO THE DEATH?
<br />YES, :t] N.0.4 PROBABLY 0 UNKNOWN •
<br />26a. HAS ORGAN
<br />❑ YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2Aa. On the beaus of examination and/or Investigation, In my opinion death enso
<br />the time; date and place and due to the cause(s) stited (aigntnane itis)
<br />ISI
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED<DEAD
<br />n TISSUE DONATION BEEN CONSIDERED?
<br />ANO
<br />27 NAME, riltLE AIVDA1;ipness cif CERTIFIER (Type or Print
<br />Steven Husen,'MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENTGRANT'EQe':;
<br />Not Appiicsb(e If 28a is NO
<br />28b. DATE FILED BY REGIS
<br />January 4, 2023
<br />(Mo., Day, Yr.)
<br />
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