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STATE OF NEBRASKA
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<br />IrHEN';1'H1S CO k CA RE$ THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW T
<br />$E A TRUE CO�Y(F THE ORIGINAL RECORD ON FILE HVITtU THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />BATE QF ISSI.I4$CE
<br />1or2ol.2Q23
<br />LINCOLN, NEBRASKA
<br />202400728
<br />SARAH BOHNENKAIV
<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 DECEDENT'S-NAAIIEi*irst, Middle, Last, Suffix)
<br />II :Freya Mee
<br />Sims.
<br />4 GiTY ANDS'TATE Ok
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />laden, Nebraski
<br />.':SOCIAL EECURIWYN lMBER'
<br />505 54 2521 _ ,
<br />It 8b FACIUTY.PMME (If not lnsdtutii
<br />m
<br />Azria Health Broadwell
<br />Bc CITY OR O WN.P DEATH (include Zip Code)
<br />Grana Island 68803
<br />[ESIDENCE STATE
<br />Nebraska
<br />9d,i
<br />tTREET AND NUMBER
<br />•
<br />d3 E i2th St
<br />9b. COUNTY
<br />Hall
<br />ac AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE Of DEATH •
<br />HOSPITAL ❑ Inpatient
<br />ter... ....
<br />❑ ER/Outpatient
<br />_DNA
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married
<br />0 Married, but separated ❑Widowed 0 Divorced 0 Unknown
<br />�kTHER &NAME (First iltiddle, Last, Suffix)
<br />Elmet >Buettpenback
<br />13 EVER IN Itt ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, orlUnk.)14o
<br />METHOD OF DISPOSITION
<br />1 Irteli [ Donation
<br />1 Cremation QEntombment
<br />Q Removal: ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo ,
<br />Otdober 7.2023
<br />OTHER l Nursing Home/L1
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />)I Hall
<br />9e. APT. NO.
<br />1Ob. NAME ;OFSPOUSE (First, Middle, Last,
<br />Sherrell Sims
<br />14a. IN FORMANT.NAM:E
<br />Brenda Wommer
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town,., State)
<br />AU Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />9f. ZIP CODE
<br />68801
<br />INSIDE CITY IMETS•
<br />YES Ell"NPU.
<br />12 MOTHER S -NAME (First, Middle, Ma
<br />Pearl Andersen
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />14tx RELATN
<br />Daughte
<br />NSHIP TO DECEDENT
<br />16c. DATE IMt?
<br />October)
<br />CAUSE OF DEATH (See ;instructions and examples)
<br />.: PART I. Enter the chain Of *write- dI*ael s, InJudes, or complications -that directly cawed the death. DO NOT enter terminal events such u cardiac arrest,
<br />mspkatory arrest, or ventdcu,ar Rhaetian: without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines 11 necessary.
<br />IMMEDIATE CAUSE:
<br />a) cerebrovascular accident
<br />IMMEDIATECA /SE (Pinel
<br />diseaes br eol d>hon r9#uitt l4
<br />In deaths
<br />Sequsrelally l et candidates, H
<br />eny, ktedieg to the cauee lid
<br />onside as •
<br />.. ..
<br />Enfsrthe uNDEIWfING 40$E
<br />(d)eaeae or injur . Oar inkisied
<br />itt )
<br />the events re
<br />LAST
<br />ng in duRr
<br />DUETO, OR AS A CONSEQUENCE OF:
<br />b)Hypertension
<br />TO, OR AS A CONSEQUENCE OF:
<br />8 PART II OTHER
<br />AS A CONSEQUENCE OF:
<br />NT CONDITIONS -Conditions contributing to the death
<br />IFNo FEMALE;.
<br />. tientwithin pw yeat
<br />Pregaatd of 9me of dceth'
<br />Net pregnant but pregnentwtthin 42 days of death
<br />Not prowler*, but pregnant 43 days to 1 year before death
<br />1:1 Unknown R'.pra rant within the pert year
<br />22d. INJURY AT WORK?
<br />❑YES, jNO
<br />22
<br />21a. MANNER OF DEATH
<br />Ea Natural a Hom(cide
<br />❑ Accident ❑padding Inveetsation
<br />0 Suicide ❑ could not be determined
<br />et to ilei'
<br />ronic
<br />t net resulting in the underlying cause given in PART L
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJU
<br />DESCRIBE HOW INJURY OCCURRED
<br />:),POA.1101t0Filt9i0M.STREET A NUMBER, APT.NO.
<br />23a.`DATE OF DEATH (ma., Day, Yr.)
<br />October 7, 2023
<br />CITY/TOWN
<br />23b. DATE SIGkED (Mo., Day, Yr.)
<br />etoT..t6.2023
<br />e the bort 04,M knowledge, death occurred at the time, date and place •
<br />:.. tet thAcause(s) stated. (Signature and TSM)
<br />Rvan D Crouch, DO
<br />23c. TIME OF DEATH
<br />10:11 AM
<br />6. DiD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YESIII NO 0 PROBABLY 0 UNKNOWN
<br />7 NAME, Ina. NO ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />210, IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />❑ passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTO
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS 14VAILA846
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0} NO
<br />At home; farm, street, factory, office building, construe
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEAT
<br />24d. Til
<br />24aOn the balls of examination endbr investigation, M my•
<br />tit tins, date and place and due to the eause(s) Aie6M. tl
<br />26a. HAS ORGAN OR TISSUE DONATIONBEEN CONSIDERED?
<br />❑YES �riaNO
<br />26b. WAS CONSENT
<br />Not Applicable if 28ate
<br />28b. DATE FILED BY REGISTRAR (
<br />October 16, 2023
<br />Yr.)
<br />
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