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<br />rtfwo, STATE OF NEBRASKA
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<br />WI EN;T HIS 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 WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12)6/2023
<br />LINCOLN, NEBRASKA
<br />1. @ECEDEN.1''B NAME (FI
<br />4000 :Vodehrtial
<br />20240073.7'
<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 />Middle, Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4`cITY AND:; 'f'AT£ OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Spalding, Nebraska
<br />T $QCfALSECURITY NUMBER
<br />5071.30-762
<br />8b. FACILITY: NAME (If not Institution, give street and number)
<br />tu
<br />a Riverside Lodge, Inc.
<br />8c..:CITY OR TOWN OF OEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />ed. STREET AND NUMBER
<br />404 WNoldla n d Dr #40
<br />9b. COUNTY
<br />Hall
<br />6a. AGE - LastBirthday
<br />(Yrs.)
<br />6b. LINDER 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 />❑ ER/Outpatient
<br />❑ POA
<br />10a MARITAL. STATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />a
<br />�.1
<br />13,EVERiN US ARMED FORCES? Give dates of service if Yes.
<br />2 (Yes, No, orUnk.) No
<br />1:FATHER'S: NAME (First, Middle, Last, Suffix)
<br />Martin 16/1 MGKay
<br />16. MED ODISPOSITION
<br />j Cremat oi! { Entombment
<br />Remove
<br />(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH: (Mo» Oayt
<br />November.l9,. 2023
<br />6. DATE OF BIRT1i (Mo., Day, Yt)
<br />July 8, 1928
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (specIfy)ASSISTED LIVING
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Martin Charles Vodehnal
<br />14a. INFORMANTRNAME
<br />Theresa Ann Reed
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1241M0THEfFS-NAME (First, Middle, Malden Sumame;
<br />Anna. Carlson
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />7a. FUNERAL: HOME.NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />It Faiths;Funera1 Home, 2929 S. Locust Street, Grand Island, Nebrask
<br />Gibbon
<br />CAUSE OF DEATH (See.inetrtlatlons and examples)
<br />18. PART 1. Enter the Chain of event- 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. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) respiratory failure
<br />:e?
<br />t1Q IN$iDECITYtifMnS
<br />YES NO
<br />14b. RELATIO
<br />Daughter
<br />16c. DATE (Mo., Day, Yi
<br />November 21;. 20.23
<br />ieeibef1T
<br />STATE.
<br />Nears'
<br />MA entrgE CAUSE (Pinp1
<br />dtawse of uonelhion riaifh.[p
<br />massy Itet'oond1dcns, if
<br />any, laadhp to the cabse.beted
<br />on: Line a
<br />liter the UN DE1!H.tfIN# SrAU#E
<br />dr Jnjpry tart ldplted
<br />the events re Ring In.
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) interstitial lung disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) alpha 1 antitrypsin deficiency
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART If• OTNER SIGNIFICANT CONDITIONS-Condltions contributing Mine death bolt n
<br />congestive E#®art fallttree
<br />IF FEMALE.
<br />.Net i4roer16ti11
<br />year
<br />death
<br />blit roll t, but pregnant MOM 42 days of death
<br />❑... Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ unknown H pregnant within the pest year
<br />22a DATE OF INJURY (Ma., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES :❑ NO
<br />LOGATION:QF MOO STREET & NUMBER, APT.NO. CITY/TOWN
<br />21a. MANNER OF DEATH
<br />® Natural ©Honnelde
<br />0 Accident ❑ pending lnveatigeaon
<br />❑ Suicide 0 Could not be determined
<br />e*u)ttn
<br />10 Ye
<br />nderlying cause given In PART I.
<br />21b. IF TRANSPORTATION
<br />❑ Ddner/Operator
<br />❑ Passenger
<br />' ❑ Padestnan
<br />0 Other (speedy)
<br />INJURY
<br />onset to dea
<br />19. WAS MEDICAL EXAMINER,
<br />OR CORQ$F. CONTACTED?
<br />❑ YES ®No
<br />21c, WAS AN AUTOPSY PER
<br />❑ YES Ili Nd
<br />21d. WERE AUTOPSY FINDINGS AVAU ABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YEs EJ NQ
<br />22b. TIME OF INJURY
<br />22c.
<br />LACI
<br />OF INJURY -A$ home, fern, street, factory, office building, construction .I$t,a ((
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />23a GATE OF'DEATH (Mo., Day, Yr.)
<br />November 9, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />N4vertber. 27.2023 08:18 PM
<br />To;t*N bout 0*t y knowledge, death occurred at the time, date and place
<br />end Mitt tittle ::aause(s) stated. (Signature and Title)
<br />Isaac J, Berg, MD
<br />25.'DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ® NO ..❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24a. qn ant Mals of examination and/or investigation, In mysp inion desat essurritd
<br />4110tint.; date and place and due to the cause(s) stated. (aignaturo sad Late)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />28a. HAS ORGAN OR TISSUE DONATIONBEEN CONSIDERED?
<br />❑ YES NO
<br />:;NAME TITLE #O A DRESS OF CERTIFIER (Type or Print
<br />(saec J..Berg, MC, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED? 'I
<br />Not Applicable If 28a is NO YE
<br />❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 28, 2023
<br />
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