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STATE OF NEBRASKA
<br />wi am. #rg ATiv ttthtr 10win T4y1. lolls
<br />WHEN THiS COPY CARRIES THE RAISED SEAL OF STATE OFANEBRASKAr !T CERTIFIES THE DOCUMENT BELOW TO
<br />BE kiTPUECC1PVOPTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA .]DEPARTMENT OF HEALTH AND
<br />` HUMAN SERVICES, IlTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ViTAL RECORDS
<br />DATE OF ISSUANCE
<br />... ...... .......
<br />..................... .......
<br />............... ..............
<br />..... ...... ............
<br />3/1...1/2024.
<br />UNCOLN, NEBRASKA
<br />202401 `522
<br />SARAH BOHNENkAIMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OP HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 [#EOEDErms-NAME;;(First, Middle, Last, Suffix)
<br />1N(Iliam Jack hottenkirk
<br />GITYANDS'rATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Isl.and,Nebraska
<br />7 SOCIAI. SECURITY NUMBER
<br />6057.09$14
<br />da. AGE Last Birthday
<br />(Yr..)
<br />67;
<br />81E FACILITYNAME (If not Institution, give street and number)
<br />.J Veterans Affairs Medical Center
<br />8c CITY OR 1"owt1 OF DEATH' (include Zip Code)
<br />Grand island 68903
<br />9a. RESIDENCE$TATE
<br />Nebraska
<br />9d::STREET'AND NI MBER
<br />Kuestsr Lake
<br />Sb. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />St?PLACE OF DEATH
<br />HOSPITAL le Inpatient
<br />0 ER/Outpauent
<br />❑ DOA
<br />teat MARITA(.;STATUS:AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />S 11.. FATHERISVNAME. (First, Middle, Last, Suffix)
<br />William :Jack Shottenkirk
<br />13.e.EVERINALS. ARMED FORCES? Give dates of service H Yea.
<br />(Yes, No, or Unit.) Yes 1973-1975
<br />u . 1S. METHOD OF DISPOSITION
<br />�' ❑ BWial ❑ Donation
<br />{ Crpntattoi [ Entombment
<br />j Rdtmaral. . Oilier (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />iOb. NAME.OF SFOUSE(FI
<br />Vicki Frederick
<br />14a INFORMANT -NAME
<br />Vicki Shottenkirk
<br />16a. EMBALMER -SIGNATURE
<br />I
<br />r
<br />Not Embalmed
<br />HOURS
<br />MINS.
<br />24 02635
<br />3. DATE OF DEATH (AMoo61E,*r.
<br />February 20, 2024.
<br />6. DATE OF BIRTH (Ma,
<br />August i..:1., 1956
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />ed. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Hospibe FaellI y
<br />i.9g.ANSIDEGIVEIJMITS
<br />YES:: Nt7
<br />it, Middle, Last, Suffix) If wife, give maiden neat.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumaghn):
<br />Barbara J Pokornev
<br />1eb. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17e. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town State)
<br />Al) Faiths Euneral Home, 2929 S. Locust Street, Grand Island; Nebraska::
<br />CAUSE OF DEATH (See InstructIo s and examales)
<br />14. PAW!' I. Enter the chain of events- diseases, Injuries, or compllcationadhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respkatory 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 />liakilaaanakaaa(Fhrel `:: a) Cholangitis
<br />Owen or eo)iilition rsaultii g:
<br />Sequentially list conditions if
<br />any, leading to the cans.Ibted
<br />orl:llne M
<br />Entor tha.UNON..K.Vi . #;nA.USE
<br />lined
<br />the events resulting In death)
<br />LAST
<br />18-PART;II
<br />HE
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Biliary obstruction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />a) Adenocarcinoma of pancreas with..
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)
<br />•
<br />static d113e
<br />GCr *FICANT CONDITIONS -Conditions contributing to the>deathl art ntot
<br />20.1F FEMALE:
<br />. Q Notpragnantwifitlnpastyear
<br />d Pregnentatidnaot deatlh
<br />bbb ❑ Not preptat ! buiP4ij uM within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />unknown, if.pregnant within the pest year
<br />DATE.OF'INJU
<br />22d1 INJURY AT WORk?
<br />❑ YES ❑ NO
<br />2,21.a0C41.1QR F' INJU
<br />Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hoiniptd5
<br />❑ Accident ❑ P1?sding lnvestigailen
<br />❑ Suicide ❑ Could not be determined
<br />F4rlting In the underlying caws given in PART I.
<br />22b. TIME OF INJURY
<br />22c PIAL
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />February 20, 2024
<br />23b. DATE SiGNED (Mo., Day, Yr.)
<br />Febrt arv:21.2024
<br />OFIN!IURYAtham
<br />CITWTOWN
<br />23c. TIME OF DEATH
<br />07:30 AM
<br />tile Pact of+ttp knowpdge, death occurred at the time, date and place
<br />due ti+tlibbiduse(s) stated. (Signature and Two
<br />Jennifer King, MD
<br />21. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />>I YES an .NONO PROBABLY 0 UNKNOWN
<br />I
<br />21b IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Passenger
<br />pedestrian
<br />0 Other (Specify)
<br />14b. RELATIONSHIP l ©ECE!
<br />Spouse
<br />1Sc. DATE (Mo,
<br />Februarv:21
<br />TATE
<br />Nebraska
<br />17b. Zm Code
<br />68$01
<br />APPROXI MATE INTERVAL
<br />Onsee9R.
<br />TWQ:!;Months.:::.
<br />onset te'death
<br />Two Months •
<br />19. WAS MEDICAL EX ! NEl
<br />OR CORONEEIOO1NTACTED?
<br />CI YES. .., tit NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO.
<br />21d WERE AUTOPSY<FIND1NGs 4VA*LABC.E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES . ❑. NO::...
<br />) tnn,.atreet, factory, office buildinng, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD •
<br />24. On thifriale of examination and/or Investigation, In my opinion deaptmeeurnitl 4t
<br />the 111115, date and place and due to the sausa(s) stated. (signattue,and,7'ate)
<br />26a. HAS ORGAN ;OR TISSUE DONATION BEEN CONSIDERED?
<br />27: NAME,1lT E E ADDRESS OF CERTIFIER (Type or Print
<br />"jenniferNIVAID, 2201 N Broadwell Ave, Grand Island, Nebraska 68803'
<br />I2811. REGISTRAR'S SIGNATURE
<br />2Sb. WAS CONSENT GRANTED?:.
<br />Not Applicable if 26a is NO .,., 0
<br />28b. DATE FILED BY REGISTRAR (Mo Day Yr.)
<br />February 27, 2024
<br />CO
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