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STATE OF NEBRASKA
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<br />WHEN t HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />"BEA TUE COPi OP THE ORIGINAL RECORD ON FILE WITH TI1E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN` SERVICE'S, VITAL. RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />pA 1 E Oil:ISSIIAhtGE .. .
<br />9(10/2{3
<br />LINCOLN, NEBRASKA
<br />202401501'
<br />r
<br />,, . zr"ll';t f;a
<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 />DECEiNT';•NAME: (F.frst, Middle, Last, Suffix)
<br />taro) Rae West -
<br />4.'CITY AND STATE *TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wahoo, Nebraska.
<br />2. SOCRO-SE04#R)Tf NumaaR '
<br />t18 54 B&63
<br />ba, AGE - Last Birthday
<br />(Yrs.)
<br />76
<br />« ' Sb. PAC LA' -..NAME tintpt Itlitttittton, give street and number)
<br />.41 AtWtiderness Hills Memory Care -
<br />,m
<br />8c.;.C.ITY Ot# TNiN OF DEAm (intrude Zip Code)
<br />UriGoIn 68816
<br />8a RESIDENCE -STATE
<br />Nebraska
<br />•STREETA(ONUMEER,;
<br />2413 N: Oester Aya..
<br />10iiMARiTA4.8TATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />9b. COUNTY
<br />Hall
<br />FATHERS NAME (Fila(, Middle, Last, Suffix)
<br />Ohades :. Nt leak
<br />13. EVER iia U'S AR�MED..FORCES? Give dates of service if Yes.
<br />8 (Yes No, or Unk) NO.
<br />u 15. ME1OD'OF D($P.QSIT)ON
<br />ar
<br />E Andel D irtalion•
<br />Crernstittit Entombment
<br />❑ Rifmoval }Other (Specify)
<br />bb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />es, PLACE QFOEATH
<br />HOSPITAL D inpatient
<br />0 ER/Ou patient
<br />C:1 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OE DEA
<br />September
<br />6. DATE OF BIRTH{(Mo., Disy S
<br />May 31, 1946
<br />OTHER. 0 Nursing Home/LTC
<br />0 Decedent's Home:
<br />® Other (SPeoify)ASSISTEp .LIVING
<br />8d. COUNTY. OF DEATH
<br />Lancaster
<br />Se. APT. NO.
<br />9f. ZIP CODE,
<br />68803
<br />10b. NAME OF (First, Middle, Lest, Suffix) If wife, give m
<br />Wayne A West
<br />112 MOTHERS.NAME (First,
<br />Ruth ` Larson
<br />14a. INFORMANT -NAME
<br />Wayne A West
<br />16a. EMBALMER•SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />'E lie fta)14L MOMS NAME AND MAIUNG ADDRESS (Street, City or Town, State).
<br />All Faiths Funeral'IHome,2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH(See Instruotioni
<br />16b. LICENSE NO.
<br />Middle, Maiden
<br />CITY / TOWN
<br />Gibbon
<br />and examples)
<br />IL> PART I. Enter tMcha1 of awns•-<dbeesea, M)uries, or compllcations4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reeptratnry arrest, or 'eM!1r:y)Er,lbrilierion without showing toe etiology. UO NOT ARPREVIATE. Enter only one cause on a nue. Add additions! Ieee a neceeeery. .-
<br />IMMEDIATE CAUSE:
<br />a) Alzheimers
<br />pease or condition rs6tiftInt)
<br />in
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />quentially tat sanctities*, if b) .
<br />rty, ban 00$ Id tha;cauaaJ)ctaa
<br />xtana s DUE TO, OR AS A CONSEQUENCE OF:
<br />Eitterthat4NDER4YlN4.CSsjtI:. C)
<br />(disease: or in)aty .that trfit3et
<br />the stares resuutngin death). DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1LPARTf
<br />N
<br />0. IFFEMALE;...
<br />Not{ rtignanttvtlt fp<a?Y
<br />Pregnant a thhe of dsato r.
<br />U ttcf pragneit but preitruin within 42 days of death
<br />❑ Not pregaard, but pregnant 43tuye to 1 year before death
<br />0 Dnhnown If pretreat* Within the past year
<br />(CANTCONDiTIONS-Conditions contributing to tha death but natres
<br />Yr.)
<br />21a. MANNER OF. DEATH
<br />Natural ©Homfuide
<br />0 Accident ❑ Pending iniaatigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE CIF I
<br />d. INJURY AT WORK? 22e, DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO., -.
<br />22f .LOCATION OF INJURY .• STREET & NUMBER, APT.NO.
<br />23a. DATE CF`DEATH (Mo., Day, Yr.)
<br />September 1, 2022
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />° eotefribtiir 7, 2022 10:10 AM
<br />Tolhe beat of gi Oiowtadge, death occurred et the time, date and place
<br />ii iOu to tha tuivaa(s) stated. (Signature and Title)
<br />Jamie;P . Peters, APRN
<br />28. bib .•t BAC,GO USE ONTRIBUTE TO THE DEATH?
<br />D YES NO PROBABLY 0 UNKNOWN
<br />2?> NAME . T(TI AND ADDRESS OF CERTIFIER (Type or Print
<br />Jamie R `Peters, APRN, PO Box 1227, Bellevue, Nebraska, .68005
<br />28a. REGISTRAR'S SIGNATURE
<br />rig in the inderiying cause given in PART I. •
<br />21.0, IF, TRANSPORTATION INJURY
<br />❑ Drlaar/Operator
<br />0 Peaaenger
<br />❑:pedestrian
<br />❑ Other (Specify)
<br />9g•iNSt" Orr LIMiTS
<br />YES No
<br />14b, REI.ATTONS(1tP TF164abE►;IT >`.
<br />SDDuse
<br />16c,. DATE tato Day:Yr
<br />SeptembEE 3.2Q2
<br />STATE
<br />Nebraska
<br />IS WAS M
<br />OR C
<br />® YES
<br />TA0,7V t -
<br />21d. WERE AUTOPi
<br />TO COMPLETE
<br />0 YES'
<br />URY At home,' farm, street, factory, office building, construction is
<br />STATE
<br />Z 24a. DATE SIGNED (Mo., Day, Yr.)
<br />uFQ1
<br />gr
<br />U
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)(
<br />IGS AYAKA16t t
<br />EOF DEATH?.:
<br />2r ;pATB !?F tiIURY (1VtaDay;
<br />24b. TIME OF DEATH
<br />24p> Otr the tants of examination and/or investigation, M my opl ion dabtft eccurfai et
<br />the time?date and place and due to the tauae(s) stated. ISfiptrdure area
<br />26a. HAS ORGAN OR TISSUE DONATION' .B, BEEN CONSIDERED?
<br />0 YES 1E110.
<br />26b. WAS CONSENTORANTED...
<br />Not Applicable if 28a Is NO 0 YES s'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day; Yr)
<br />September 12, 2022
<br />
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