|
��IrgltV,natt...
<br />STATE OF NEBRASKA
<br />RI000411NWf'�a ar0iidttt� !/tOflweintA ..(-
<br />HEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW Ti
<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 />DATE OF;/SSUANiE
<br />1/11/2023
<br />LINCOLN, NEBRASKA
<br />I. DECEDENTS=NA
<br />Leo i ienl jr.
<br />Middle,
<br />achmuller Jr
<br />(Fina,
<br />2024011 45
<br />SARAH BORNE.
<br />ASSISTANT STATE REGISTRAI
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF;DEATH
<br />Last, Suffix)
<br />4. CITYAND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, Nebraska:::::
<br />7 SO I AL SECURI'r r NUMBER
<br />507 ii6�9Z84
<br />5a: AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />8b. FACILITY -NAME (If not bled lution, give street and number)
<br />CHI Meath St. Francis
<br />8c.. CITY OR; TOWN OF DEAT
<br />Grand Island 68603
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />(Include Zip Code)
<br />9b. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Bak PLACE OF DEATH
<br />HOSPITAL va Inpatient
<br />0 EFL/Outpatient
<br />Q DOA>;
<br />9c. CITY OR TOWN
<br />Grand island
<br />2. 8X
<br />Neale
<br />UNDER 1 DAY
<br />HOURS
<br />3. DATE OF!.
<br />December
<br />Sc
<br />MINS.
<br />ER 0 Nursing Home/LTC
<br />❑' Decedent's atoms
<br />Other (Specify)
<br />' 8d. COUNTY OF DEATH
<br />Hall
<br />9d s'IREET AND NUMUER
<br />1515 iltltrKtSOf Road '
<br />10a. MARITAL STATUS AT OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHERS NAME (Pirlrt, Miadle, Last, Suffix)
<br />leo Henry Mechrrtuller, Sr
<br />13. EVERIN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yas, No, or Unk.)IYes 05/28/1966-05//22/1972
<br />1S. MaEmOD OF:DIBPOS►IAON
<br />O Burial j oonatlaln
<br />®:;Cremation 0 Entombment
<br />❑ Rernovel �] Other (Specify)
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle,, Last, Suffix) If wife, give mai
<br />Kathleen Elaine Hanzl
<br />12 MOTHERS -NAME (First, Middle,
<br />E►leel! Shannon
<br />14a. INFORMANT -NAME
<br />Kathleen Elaine Machmuller
<br />Maiden!
<br />g0 tDEPITYtlpp;
<br />I1 YES I NO
<br />tab -RELATE)
<br />Spouse
<br />NWT`%
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1141. FUMES
<br />NI.F0
<br />10. LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />rel Home, 2929 S. Locust Street, Grand Island,,: Nebraska
<br />CAUSE OF DEATH (See Instructions ns and examples)
<br />17b ZipC
<br />68801'
<br />18. PARTt. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory street, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional l nes If necessary.:
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAI*E(Fiaal a) acute respiratory failure
<br />dWaee ortpmgtlonr$u fktti:
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially flet cwutldona, k b)bilateral pleural effusion
<br />a v, leedlgg to sae iauss Sited.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)volume overload
<br />the,events resul
<br />LAST
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) septic shock
<br />18. PARTIL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but notresuking in the underlying cause given In PART!.
<br />metastade Squamous cell carcinoma of lung, pancytopenia due to chemotherapy, neutropenic fever, coronary artery disease,
<br />ischemic cardiomyopathy, diabetes mellitus type 2, orthostatic hypotension, benign prostatic hypertrophy, urinary rete
<br />28. IF::FEMALE.;:
<br />Not prlgpaf t v4thud ale
<br />PPoghalttatthflM oraaath::�
<br />❑ ;INt pregnerk but piegnsnt within 42 days of death
<br />❑ Not pregnant, bad prsllnent 43 days to 1 year before death
<br />Unknosm PpregriaM wtthet the pain year
<br />21a. MANNER OF DEATH
<br />Natural E Homicide
<br />❑ Accident 0 Pending Invaetigatjop
<br />0 Suicide 0 Could not be determined
<br />:21b 0E:TRANSPORTATION INJURY
<br />t:lb/i0Moperator
<br />© Paca nger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />18. WAS MEDICAL EXAMINEE
<br />ORCOROWROONTAtIRD?
<br />❑ YES
<br />21c. WAS
<br />❑ YES
<br />21 d. WERE AUTOPSY FINDINGS A1tAltAt
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES I NO
<br />22a: DATE OF )4i3URY (Mo flay. Yr.)',
<br />22d. INJURY AT WORK?
<br />OYES :.ONO.
<br />22b. TIME OF INJURY
<br />22c. PLACE
<br />22e DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION ' OF INJURY,- STREET 3 NUMBER, APT.NO.
<br />a.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 29, 2022
<br />cITY/TOWN::
<br />F It4<IURY•At horns, farm, street, factory, office building, const,
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 80..2022 02:44 PM
<br />23L£ Tothe bat of Illy knowledge,. death occurred at the time, date and place
<br />and due to the Ouse(*) stated. (Signature and Tale)
<br />Jay C. Anderson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />2 YES ❑ NO .❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />DYES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME t
<br />24o. Ptf,ONOUNCED DEAD (Mo., Day, Yr.)
<br />24:. O.n ata heels of examination and%orinveetlgatlon, In my ophdon di..
<br />Me Sinai date and place and due to the cause(*) stead. (aiptahue,
<br />SSUEDONATION BEEN CONSIDERED?
<br />27 NAME, I1TLE:ANDADDREss OF CERTIFIER (Type or Print
<br />Jay C'. Anderson, MD, 729 North Custer Avenue, Grand Island. Nebratka, 68803'.'
<br />2$b. WAS CONSENT NTE04
<br />Not Applicable if 26a is NO I YES
<br />28b. DATE FILED BY RLQ
<br />January 4, 2026
<br />Day
<br />
|