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<br />STATE OF NEBRASKA
<br />.2:"Itliifigmyt.f , ih."ilNfadat a s scttl/YCffQftal3 „min
<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 WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />•
<br />DATE t7F`1SSEIiAAtrE
<br />'2/20/2022'.
<br />LINCOLN. NEBRASKA
<br />202400912
<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 />wr.1 ,t3ECEtlEN CSS NAME >)ret Middle, Last, Suffix)
<br />Obert : flerleRosso
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />CERTIFICATE OF..DEATH
<br />Chambers,. Nebraska
<br />SOCIAL SECURITY NUMBER
<br />508-40-1874
<br />Sb. FACILITT NAME (ifnot Institution, give street and number)
<br />• 1:803 Lafayette
<br />8t : CITY::oR W . O ' DEATM{Include Zip Code)
<br />€ani Islnd:;:8803
<br />a1 RESItDENCE-STATE
<br />Nebraska
<br />... I:
<br />ci. STRI Et A ND N J1. BEi
<br />1803 Lafayette
<br />41 $TATtJSA*TIM
<br />[I Morrie t,'iwt separated
<br />1 SATHER's-Ni
<br />Everette I:tdsso
<br />9b. COUNTY
<br />Hall
<br />SWAGE - Laildarthdsy
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS. DAYS
<br />Ba.:PIACE•OF'DEATH
<br />HOSPITAL A3 Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />OF DEATH ® Married 0 Never Married
<br />Widowed 0 Divorced 0 Unknown
<br />rat; Middle, Last, Suffix)
<br />i3 avaR 1N U S; ARMED'f ES7 Give dates of service N Yes.
<br />(Yes: No, of Unk.) No •
<br />16. M.ETIfOD.OF. DISPOSITION
<br />0 Burial 0 t oration
<br />• Cremation [, Entoi ibrnent
<br />••
<br />ovN` DONier(8peeifY)
<br />9c. CITY OR TOWN
<br />Grand; Island
<br />HOURS MINS.
<br />3, DATE OF DEATH 00., DAY Yr
<br />Deaembet 11 2022
<br />6. DATE OF SIRTH.(Mo.,
<br />February 2S,1::937
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (SpecM7
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />Yt)
<br />K. ZIP CODE
<br />68803
<br />lob. NAME OF SPOUSE'(Firat, Middle, Last, Suffix) If wife, give lnaldep n4etK
<br />Lavonne Landgren
<br />14a. INFORMANT -NAME
<br />Lavonne Rosso
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Z MOTHER'S -NAME (First, Middle, Maiden. Surname
<br />Helen Sturek
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />11a.,FUNERA4;HOME IIAME AND MAILING ADDRESS (Street, City or Town;State)
<br />Curran Funetal Chapel; .3005 S, Locust St., Grand Island Nebraska
<br />in math)
<br />CAUSE OF DEATH (See lost
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />tiotls.and examples)
<br />.dames*, Injdrws, or complications -that directly caused the death. DONOT enter terminal events such as cardiac arrest,
<br />r fBntaaaon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add eddidonai lines H necessary.
<br />IMMEDIATE CAUSE:
<br />4) myocardial infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially oat condition*. .If . b)coronary artery disease
<br />, ,laedip9 to the;caua►: ueted
<br />Eaitlrthe,;) •L
<br />k.YINiiC.Ati1.t.'I
<br />` Sorekleor7OERhBie h
<br />.tits events rasa nein
<br />LAST •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />A)
<br />dpi DUE TO, OR AS A CONSEQUENCE OF:
<br />(I)
<br />si s otry («i Its
<br />YES
<br />14b, RELATiONE,HIPTODE.e )7
<br />wife .,
<br />PART 1i E17HER.SIGNINGANTCONDITIONS-Conditions contributing to the death b• ut neitresultingin the underlying cause given in PART!:
<br />• •hypertension. hypetltpidemla, history of tobacco abuse, lumbar spinai.stenosis, peripheral neuropathy
<br />FEMALE..:>
<br />Nottl' itgttsrrlWi hin pest,:yaar . •
<br />PregimM al fe a of deaiR. :
<br />progoarit, trait pregnant Within 42 days or death
<br />pregnant, but pregnant 43 days tot year baton death
<br />,,Areariont wi tkt *ripest year
<br />",:DATE:OF
<br />URN" (M0.; Day, Yr.)
<br />r�tURY AT WORK? .
<br />Wks ONO
<br />21a. MANNEROF DEATH
<br />® Natural 0 Hoiiticlds
<br />0 Accident 0 Pending Investigation
<br />Suicide 0Could not be determined
<br />22b. TIME OF INJURY
<br />21;b.:I:F..TRANSPORTATION INJURY
<br />Dtteer/Operator
<br />:Q Passenger
<br />©Pedestrian
<br />0 Other(Specify)
<br />t9 WAS MEDICAL EXAMINER:
<br />ORCOROt(;BR_CONTAt'TLCf7
<br />Q YRS
<br />21S. WEREADTCPS , SONGS AVAILABLE
<br />To COMPLETSCA i$E OF DEATH?
<br />0 YES
<br />22c. PLACE OF &IJURY At home farm, !treat, factory, office building, cons•t
<br />22... DESCRIBE HOW INJURY OCCURRED
<br />TION OF INJURlk' .- STREET R NUMBER, APT.NO. CITY/TOWN
<br />23a DATE OF 'DEATH -(Mo., Day, Yr.)
<br />December 11; zo22
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Dl0f3tbdr 1?. 2022 Unknown
<br />tad. Tti the beat otos" knowledpe, death occurred at the time, date end piece
<br />bpd doe to th..r eevee($ stated. Ieienatun and Title)
<br />:Jay C. Anderson, MD
<br />S, II 1OBttGt"G USE;CONTRIBUTE TO THE DEATH?
<br />YE$ .ii NO :30 PROBABLY 0 UNKNOWN
<br />V
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />cti
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 244. TogPRRONQUNCED DEAD
<br />4e+4n the bis of examination and/or Investigation, in myophnen Wath rntctlrr4d atf
<br />the titiiii, data and place and due to the cause(1) stated. (8lgnatdn,Ut
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES* •
<br />.:NAMLT1TLE. NDADDRESSOFCERTIFIER (Type orPrint
<br />ey C Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 6881
<br />214: REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26s Is NO
<br />28b. DATE FILED BY REGISTRAR (Mo , Day, Yr.)
<br />December 19, 2022,
<br />
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