|
STATE OF NEBRASKA
<br />rn
<br />'I�fO,tttrNAa�A ttr:vtt149rt1Wf11ti�t? Ylliri4'ftMt a veyllAiATRflRtt-'
<br />Irtyyym
<br />loll Olio I
<br />tl°l,°A1ei);N)(Ji
<br />it
<br />'x833'
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE ATRUE COPY OF THE ORIGINAL RECORD ON FILE WITH TIt1E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11312024
<br />LINCOLN, NEBRASKA
<br />S
<br />202....:o<:1 44
<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 />1 #I EDENT S NAME,:;(First, Middle, Last, Suffix)
<br />Ph)lllp ;Jamets #'larders
<br />CERTIFICATE OF DEATH
<br />4 CITYAND $TATE OS TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7 OCTAL. S. ECuRITY itil)MBER
<br />08,8644433-P
<br />Ba. AGE - Lest.BlrtiAday
<br />(Yrs.)
<br />8b FACIGTY•NAME (if not Institution, give street and number)
<br />3211 Dixie Square
<br />Sc CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lsli Ind 68803
<br />9a RESIDENCE-S'rATE
<br />Nebraska
<br />9d.::STREET AND NUMBER
<br />3211 Dixie Square
<br />9b. COUNTY
<br />Hall
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />80. PLACE OF DEATH
<br />HOSPITAL ['Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />19O MARITAL';STATLiS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER $•NAM$ (First,
<br />Delbert Harders
<br />13 EVER IN U.S. ARMED, FOR
<br />(Yes, No orUnk.) NO
<br />Middle, Last, Suffix)
<br />5? Give dates of service if Yes.
<br />15. METHOD OP OtsposrrioN
<br />Burtal ❑ Donation
<br />Cremation ❑ Entombment
<br />Removal; [leeer(Specify)
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give
<br />Terri Lynn Vyhnalek
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF Cti»ATW tSo, Duy, Yr.)
<br />December 2t)� 2023
<br />S. DATE OF; BIRTS (Mo., DayiYr.)`
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />I12.8 017.0gWS-NAME (First, Middle,
<br />Ruby Rickert
<br />14a. INFORMANT•NAME
<br />Terri Lynn Harders
<br />18a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a..FUNERALHOMENAME AND MA LING ADDRESS (Street, City or Town,, State)
<br />.,:eitrran.Ftinerat Chapel, 3005 S. Locust St., Grand Islanit Nebraska
<br />CAUSE OF DEATH (See.lnstructions and examples)
<br />r8s
<br />'fMtlM1T8
<br />❑ Nrs
<br />14b. RELAY
<br />Spouse.
<br />18c. DATE (Mo.
<br />December a
<br />SHIP TOOWEDENT
<br />1, A
<br />18. PART I. 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 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) metastatic cholangiocarcinoma
<br />IMMEDIATE CA..,
<br />digs...Or•yor lOnrasalttr>W
<br />In
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially gat conditions, if b)
<br />airy. wafts to the cause listed
<br />Id
<br />E TO, OR AS A CONSEQUENCE OF:
<br />er the..UNDERLYINti�:t
<br />ease ar inj chat 9Ntt ited
<br />the events resulting In death):.
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 ::PART i!. crRIERfifIGNIfICANT CONDITIONS -Conditions contributing to tha:death but i
<br />20. IF FBMALE:
<br />Not pregnard wialBa past.:year
<br />�+t Pregnentatt lieofdead?;
<br />❑: Not ProMfgik, but jlregria.nt within 42 days of death
<br />0 Not pregnant bbd pregnant 4$ days to 1 yearbefore death
<br />unknown ifpregnantwithin the past year
<br />22a' DATE OF:INJURY (1410., Day, Yr.);
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f LOCATION>I
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />wAsmtlidtbALEX4MINER
<br />OR CORONERf•CONTACTED?'
<br />❑ YES
<br />...t'Igo No
<br />21c. WAS AN AuTomSyA E0?
<br />ng..in tho underlying cause given in PART
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Dfiver/Operator
<br />❑ Psatenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />•
<br />❑ YES Fj NO.
<br />21d. WERE AUTOPSY SINDINGS'A1rA)LABLE
<br />TO COMPLETE CAUSE OF,DEATH?
<br />❑ YES ' {
<br />22c. PLACE OF INJURY.At home, farm, street, factory, office building, construct
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 20, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 27, 2023
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:57 AM
<br />bRat;ol:ri y hnoWledge, death occurred at the time, data and place `.
<br />due to he cause(S) stated. (Signature and Title)
<br />Ryan Ramaekers, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />liw
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF
<br />24d. TII
<br />24e, On the basis of examination and/or investigation, In
<br />> the tto., date and place and due to the cause(s) *tined.'.
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />yes NO '❑ PROBABLY
<br />0 UNKNOWN
<br />2 NAME,11*L AND ADDRESS dF CERTIFIER (Type or Print
<br />Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebra8ka, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ® NO
<br />RONOufiCED DEA
<br />28b. WAS CONSENT GRANIED?.
<br />Not Applicable if 28a Is MO'
<br />NC
<br />28b. DATE FILED BY REGISTRAR (Mo., D
<br />January 2, 2024
<br />0
<br />
|