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WHEN;THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKAt IT CERrfpIES THE DOCUMENT BELOW TO
<br />BE A TRUE copyitiFTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />1UMAN SERVICES,'SITAL RECORDS OFFICE, WHICH IS THE'LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />202401544
<br />SARAH BOHNENKAMY
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1,esesDENI:S,NAME .(Firet, Middle, Last, Suffix)
<br />James Hohnke
<br />CERTIFICATE OF DEATH
<br />4`O ITYAND:$TATE t,t TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand I9land„Nebraska
<br />Ser. AGE - Las# Birthda y
<br />Yrs.)
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />E
<br />X.
<br />G
<br />7, SOCIAL SECURITY NUMBER
<br />'507,38.6489
<br />IIEFAGIUTY IAME(If not Institution, give street and number)
<br />Riverside Lodge, Inc.
<br />Sc,CITY_ OR;TOWNOF::DEATH (include Zip Cods)
<br />:Grand lslah8.18801
<br />9.. RESIDENCESTAT@
<br />Nebraska
<br />9d ::$TREET.4ND 1V Nr8!»R
<br />±404 Woodland Dr e
<br />9b. COUNTY
<br />Hall
<br />6tw Pt.Ace sE Dt~ATH
<br />HOSPITAL: 0 Rnpattent
<br />" ❑ ER/Outpatient
<br />❑ DOA
<br />196. MARITAL' STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.:FATHER$NAME :(Fret, Middle, Last, Suffix)
<br />Frederick Hehnke
<br />13. EVER IN:0 S ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link.) NO
<br />18. METHOD OF DISpOSI nON
<br />;y Bur(al :I QDonstlon
<br />Q CrematiCn QEntombment
<br />Q Renlovali Q.Othier (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 03067
<br />3. DATE OF DEATH.(Mo,, O y,:);
<br />February , 20«24.. ...
<br />6. DATE OF BASH (MO:, Dsj Yr.)• , ;>
<br />April 3, 1837
<br />OTHER 0 Nursing Home/LTC :.MospIce Facility
<br />0 Decedent's Home
<br />I Other RIFIK WASSlSTED LIVING
<br />I8d. COUNTY OF DEATH '
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lab. NAME OF SPOUSE(First, Middle, Lest, Suffix) If wife,
<br />Doris Clay
<br />14a INFORMANT..NAME
<br />Doris Hehnke
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />164. CEMETERY, CREMATORY OR OTHER LOCA'
<br />Westlawn Memorial Park Cemetery
<br />17a FUNERAL. HOME .NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />.:All'FaitheiYurierat Home. 2929 S. Locust Street. Grand Island: Nebraska:
<br />CAUSE OF DEATH (Se
<br />f
<br />1NINDEtSTYLIMITS
<br />111 Y03. Q No
<br />12 :MOTHER:S-NAME (First, Middle, Malden Surname
<br />YNNO Kuhlman
<br />16b. LICENSE NO.
<br />1439
<br />CITY 1 TOWN
<br />Grand Island
<br />::Inetructic ns sit d examDlesl
<br />10 PART I Ent.r the chain of events- .dlsei iu, injuries, or complications -that directly caused the death. DO NOT enter terminal *vents such as cardiac west,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 11 necessary.
<br />IMMEDIATE CAUSE:
<br />9AAEOfATE clt41a1: winds . ` < a) progressive chronic obstructive disease
<br />+>ri eve orcoi ilNipn dexultIng
<br />indcaUS
<br />Sequentially list conditions, if
<br />any, leading to !ha aims! !Med
<br />• od;ald*
<br />Einar VII.;;VMMRVIING
<br />(E ii.. irijufy:nhatniht#
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)tobacco use
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />CAUSE c)
<br />feed
<br />tit* *vents resulting In de/h) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18,;;MARTiL OTHERSIGN,iwtCANT CONDrONS.Conditions contributing totha:deatI1L:
<br />. hyperwsioaiidiap0161ype 2, Atrial fibrillation, large abdominal hernia
<br />20. IF PEMALE:
<br />Not prep hpi+twitidnpa5t:,,sar
<br />Q PregnantetOmeofdewiq:
<br />Ndt prepmi, bun prsnt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days 101 year before death
<br />:Unknown If pm:1mm within the past year
<br />22 .. DA
<br />OFINJURY (Mo; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />a „ Q YES Q NO
<br />22f LOCATIONOF
<br />21st. MANNER: OF DEATH
<br />Nature/ Q Homtcia•
<br />0 Accident ©Irenlding Inv�atlyason
<br />❑ Suicide ❑ Could not be debrmin*d
<br />rftk# resulting In the underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />tib, IF TRANSPORTATION INJURY
<br />❑ nnver/OpeMor
<br />❑ PAssang*r
<br />f+edestrian
<br />0 Other (Specify)
<br />14b. RELATION
<br />Spouse
<br />'to Damon
<br />16c. CUTE SM..,'Ray, Yr.,)::.:
<br />March 6, 2024
<br />Nebraska
<br />APPROXIMATE D(TERVAL
<br />oneet#o death
<br />Years
<br />onset to death )
<br />Years / '
<br />Onto dowel
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER` CONTACTED?
<br />Q YES ®NO
<br />21c. WAS AN AUTOPSY RMMFORMYcU?
<br />QYES
<br />21d. WERE AUTOPSY FACINGS AVA1LAt TLE
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES Q>ND:::,..;.
<br />22c. PLACE: JURYliAtftdntb farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJ()RY OCCURRED
<br />iNJURY,7 STREET & NUMBER, APT.NO.
<br />23& DATE OF DEATH (Mo., Day, Yr.)
<br />February 28, 2024
<br />CITYrrowN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />M ref 4 :2024 07:35 PM
<br />2Sd Tii,Eht but of:my ktwwaetlg., d*stih occurred at tad
<br />time, date ani place
<br />and alas W d10 causos) ala/ed. (Signature and Tiers)
<br />Jane McDonald, MD
<br />25.IXD
<br />TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />I KBS PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, T1ME or DEATH
<br />24d. TIME PRONOUNCED DEAD..,
<br />34e :lin the but of *nomination and/or Inew tfyatbn. M my opbNop death Aa
<br />the Tints, date and place and due te tit► causa(s) stated. ($IgtMw #nni'
<br />❑ YES El NO
<br />27 NAME TITLE OF CERTIFIER (Type or Print
<br />Jane Mticnald MD, 800 N Alpha St, Grand Island, Nebraska 68803=
<br />28a. REGISTRARS SIGNATUREyN
<br />26b. WAS CONSENT GRANTED?.:,.
<br />Not Applicable if 26a is NO Q YES
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />March 6, 2024
<br />
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