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<br />STATE OF NEBRASKA
<br />.GrASwt> x sal9trllXlyrittSt:, a r4Mi'iN4't�sr4GttAXfiliiDt. rrrVmtls
<br />WHEN; THIS C PYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF T)4E ORIGINAL RECORD ON FILE WITH THE•NEBRASKA DEPARTMENT OF HEALTH AND
<br />hIUMAN SERVICES, 'VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />OA'lre!OP ISSUANCE
<br />2/15/2024
<br />LINCOLN, NEBRASKA
<br />202401497
<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 />CERTIFICATE OF DEATH
<br />1,0E0EDENT'S.AME(First, Middle, Last, Suffix)
<br />Steplleft Helbefd Happold
<br />4: CITY AND;eTATE DR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island,., Nebraska
<br />AL SIGUItITYTJIiMBER
<br />08 X2353
<br />Es, AGE - Last Birthday
<br />(Yrs.)
<br />81..
<br />xr
<br />0
<br />titi'FACiLIITY-NAME:(IF'not Institution, give street and number)
<br />1570 E. Giitner Road
<br />Sc j;CITY OR;TOWN QF. QE
<br />IyOn/Dha i 68832;
<br />9a: RESIDENCE -STATE
<br />Nebraska
<br />TH (Include Zip Code)
<br />(ds::, ; :RI ET AND .N'UiIOBER
<br />'1570 E Glitner Read
<br />9b. COUNTY
<br />Hail
<br />Sb
<br />DER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba: PLACE OF DEATH
<br />HOSPITAL ClInpatient
<br />Ti ER/Outpatient
<br />❑ DOA
<br />hili .MAEtITA#:':STAT(t$ AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11FATHER'StNAME (First, Middle, Last, Suffix)
<br />Jothian : Wiliarn''Happoid.
<br />IS. EVER IN LIE ARMED FORCES? Give dates of service if Yes.
<br />(Yes, Nn, or Unit.) NO
<br />18. METHOD OF DISPOSITION
<br />C
<br />Burial Donnation
<br />Cremation 0 Ent mbment
<br />I Retlwvit : Lj ntler (Spey)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />24 02024
<br />3. DATE OF CEA'rH (Mo ..Day,.1(r.}
<br />FebbrUE1 i3, 2024
<br />8. DATE OF BISTid
<br />March 24,.1542
<br />OTHER 0 Nursing Home/LTC
<br />El Decedenta_I4cme.:
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hail
<br />Be. APT. NO.
<br />Of. ZIP CODE
<br />68832
<br />9g, INSIGEG#'f^F'LIMtTS
<br />YES', NOr:
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name'
<br />Judith A Robb
<br />• 412. MOTHERS -NAME (First,
<br />Alice Faith Holbein
<br />14a. INFORMANT NAME
<br />Judith A Happold
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />16b. LICENSE NO.
<br />1092
<br />Middle, Maiden Sumam
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17e, FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />`Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CAUSE OF DEATH (See::instrudtIo
<br />nd examples)
<br />1a. PART I. Enter '1M chain of events- -diseases, injuria, or complications-thet 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 cense on a line. Add additional lines If necessary,
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pint ::::: a) metastatic lung cancer
<br />diseaa fir tofldxlorf tpyuttbfg
<br />indesdO
<br />Sequentially list condlEons, if
<br />any,, loading to the canoe listed
<br />•Einar the UNDERLYING CAUSE
<br />ntel .ae ...:.
<br />(dfaeaor INNythatliletiited
<br />tel events resulting in death)
<br />LAST
<br />11 PART DYNE
<br />hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />IIFICANT CONDITIONS -Conditions contributing to thedeath
<br />20. IF.FEMALE:
<br />E:IR•OfpresOiOt within peat year
<br />Pr`gnaa at time of death:
<br />0.24Naireglballt, butprapiient within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown,if.pregnant within the pest year
<br />221:DATEOP1NJUKY
<br />Mo , D
<br />22d. INJURY AT WORK?
<br />OYES 0 N
<br />,Yr.)
<br />21�al. MANNER OF DEATH
<br />iA! Natural Ll HotnfCids
<br />0 Accident 0 Pending Investigdtion
<br />0 Suicide ❑ Could not be determined
<br />t not resulting In
<br />22b. TIME OF INJURY
<br />underlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />© Driver/operator
<br />Passenger
<br />` 0 Pedestrian
<br />El Other (Specify)
<br />14b. RELATION
<br />Spouse •
<br />IP TO DEFSEDENT
<br />16c. DATE;(Mo., that', Yrr)...,:.
<br />Febru 15 ;2024
<br />•
<br />,; STATE
<br />.Nebraska
<br />iib P Cods ..
<br />68�)fi
<br />APPROXIMATE INTERVAL
<br />oneat;to ds*ttt
<br />2 Months.
<br />set to death
<br />19. WAS MEi iCAL EXAMINER.
<br />OR CORONER CONTA lED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTPp PERF9RMED?
<br />❑ YES I i.
<br />21d. WERE AUTOPSYfNOINGS AVA.. ABLER
<br />TO COMPLETECAUSEOF DEATH?
<br />❑ YES 0. NO
<br />22c. PLACE OF INJURY At hunk :farm...Street, factory, office building, constru
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f .LOCATION OFINJURY STREET & NUMBER, APT.NO.
<br />23rrGATE'OF'DEATH (Mo., Day, Yr.)
<br />February 8, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Februart 13, 2024
<br />CITyrrOWN
<br />23c. TIME OF DEATH
<br />05:38 PM
<br />td.'fiithe /peat !Tiny knowledge, death occurred at the time, date and place >:
<br />a due to Me; Caua(s) stated. (Signature and Tale)
<br />ChadMeth, MD
<br />25 ID D TOB& CO 8 CONTRIBUTE
<br />STATE
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />)
<br />24b. TIME OF DEATH
<br />24d.-TIME.PRONOUNCED DEAD
<br />24erOn the Oasts of examination and/or Investigation, M my opinion daatttoHunt t:Iit
<br />the fieia, date and place and due to the cause(s) 'treed. (S)gnaturs.ljad:;'INlal
<br />•
<br />U E CO BITE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATIONBEEN CONSIDERED?
<br />Q Y£$ ;' NO "] PROBABLY ®UNKNOWN 0 YES Yai NO
<br />27.NAME, TITLE AND ADDRESS, OF CERTIFIER (Type or Print
<br />Chad Vieth, MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28e, REGISTRAR'S SIGNATURE
<br />k-
<br />01-44.-1? 814eLen'k.02.71-74.
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO CIES { NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 14, 2024
<br />00
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