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STATE OF NEBRASKA
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<br />WHEN THIS COPY CAR IES THE RAISED SEAL OF STATE OF Ni BRASI(A IT CERTIFIES THE DOCUMENT BELOW TO
<br />ESL A Tit�jE COPY
<br />007 THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />:`iUMAN SERVWCES, VITAL RECORDS OFFICE, WHiCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />t?AlE.O ISSS. a,A1 E
<br />LINCOLN, NEBRASKA
<br />202401598
<br />01114.-46 1 „Lail
<br />St
<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. QEOEDENTS,NAMEMiddle, Last, Suffix)
<br />Rsandakl ..ee Rj'sland AKA Randy
<br />2. SEX
<br />Male
<br />4. CITY AND STATE pit TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />. SOOitla$ECRJR/TY NUMBER
<br />5O5 74 5226
<br />eb.RACILITY-NAMElltrhal Institution, give street and number)
<br />2815 Dallas Avenue. ...
<br />Sc..Ci M :EUA TOYS O PERTH (include,Zip Code)
<br />••dt?.GI>')Skanid '6oed3` •
<br />9a. RE91tti1;NOEiTATE
<br />Nebraska
<br />Ila. $TH T A iD M)MSsR,.
<br />2815 Dallas Ayenlue
<br />9b. COUNTY
<br />Hall
<br />106. INA2i1TA4 STATI,)SATTRIE OF DEATH ® Married 0 Never Married
<br />0 MatrhiskbeNs tsd' ❑widowed ❑ Divorced 0 Unknown
<br />11. FATHER1$4NAME.(R6at • Middle,
<br />Dille R)esskazld ;;;"
<br />13. EVER INuS:xi
<br />(Toes, No, or unit.
<br />Last, Suffix)
<br />i? Give dates of service If Yes.
<br />6a. AGE -Last Birthday:
<br />(Yrs.)
<br />70,.;.,.
<br />Sb UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />HOSPITAL ❑ tnpattent
<br />ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH IMes., Dal/.1ri )
<br />November 21, 2021..:
<br />6. DATE OF BIRTH D., Day,Yr)
<br />November;:23, :.1:95Q
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />eg INSIE CITY LIMITS'::
<br />®.SEs ❑ duo
<br />lab: NAME OF SPOUSE (first, Middle, Last, Suffix) If wife, give maiden pane
<br />Jill Marie Fuestman
<br />1 12. MOTHERS NAME (First,
<br />Gladys Pfeiffer
<br />14a. INFORMANT -NAME
<br />Jill Marie Riessland
<br />lea. EMBALMER -SIGNATURE
<br />Brandon S;-Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION.
<br />Kearney Cemetery
<br />16b. LICENSE NO.
<br />1537
<br />Middle, Maiden Sum
<br />CITY I TOWN
<br />Kearney
<br />tiNERALMOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />met Llaske Meade & Kuhl Funeral and Cremation, 2421 Avenue A, Box 777;• Kearney, Nebraska
<br />Is.PARYk
<br />61 6111#.1•.':'
<br />4eyulirdultty list cond tions,
<br />any, leading m 9ls.oawr.8;p
<br />CAUSE OF DEATH(See in t tructions and examples)
<br />die*eIss, Injuries, or complIcations.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ribalta400 wahus ehewhggthestiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional urns If necessary.
<br />IMMEDIATE CAUSE:
<br />A) hepatocellular carcinoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />TO, OR AS A CONSEQUENCE OF:
<br />the WI
<br />; LAST'
<br />reaindali'' DUE TO, OR AS A CONSEQUENCE OF:
<br />(1)..
<br />18.IlARTIi OTHEit Sl TCONDITIONS.Condltlons contributing to the death
<br />IF IsEMiA4E .
<br />. ❑Not preSMtir
<br />healaaE tit
<br />crsofikinoto
<br />❑
<br />Nat preanant,.ijut("gral*
<br />::..p
<br />Unknown W. prgnantwHitnSulpaefyeer
<br />42 days of death
<br />gays to i year Before death
<br />29ai 17ATE CIF 1NiURv:(Me,,.iDay, Yr.)
<br />21s. MANNER OF DEATH
<br />Natural ❑ Ham)
<br />oide
<br />❑ Accident 0 Pending hweatlgatkm
<br />0 Suicide ❑ Could not be deitannined
<br />not
<br />ulting In the underlying cause given In PART!.
<br />22b. TIME OF INJURY
<br />22d. INJURY AT
<br />Q YES Q NO:
<br />2
<br />22s.
<br />220PLACE OF I
<br />E MOW INJURY OCCURRED
<br />TION Of INJUI!?r:.-STREET & NUMBER, APT.NO.
<br />CITY rTOWN•':•
<br />23e. DATEDEATE (Me., Day, Yr.)
<br />Ntivs be{ 212021
<br />T@ EO (Mo., Day, Yr.)
<br />tyerllaer2i. 2021
<br />2#rl, T# thh beet o! My,ilnovi.dgs, death occurred at the time, date and pace
<br />and';R* to lh Sitisetsi stated. (Signature and Title)
<br />Richard Fres Meng, MD
<br />23b. DA
<br />23c. TIME OF DEATH
<br />03: 0 PM
<br />DID TOBACCO U E pONTRI
<br />>! BUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES NO :
<br />0 pommy 0 UNKNOWN
<br />21b, iF TRANSPORTATION
<br />i ritprlOperator
<br />M Passenger
<br />o medestnan
<br />❑ Other (Specify)
<br />INJURY
<br />a)
<br />14b. RELATIONSHIP TO DECEiNT
<br />Spouse
<br />leo. DATE (Me.., Day,.Yr.)
<br />November 29,. 2021
<br />TATE ;
<br />Nebraska
<br />t7b: Zip.>Code . ;:
<br />6$848
<br />AFFr1OXIMATE HT@RVAL•
<br />oinset:100ft#t:.
<br />I9. WAS MEDICAL. EXAMINER
<br />OR CORONER CONTACTED
<br />❑ YEs ®rip
<br />21c. WAS AN AUTOPS?PERFORMJ.D? •
<br />❑ YES ®NQ
<br />21d. . WERE AUTOPSY F' DINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />© YES ❑.::No
<br />AIWA'S home, farm, street, factory, office building, Construction'Mke, etc {SpeC
<br />•
<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 />Yds. 4n the Iasis of examination and/or investigation, in my opinion , Q.trtiliXed. a1
<br />tin time,.date and pace and due to the cause(s) stated. (Signature ani/pile!
<br />❑ YES NO
<br />'r.
<br />tom Ei 11T .SAND ADDME*8 OF CERTIFIER (Type or Print •
<br />RICRE d oru202l3 MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26s REGISTRAR'S MONATUfiE ✓t e/?.r+ c
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ TES
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo Guy Yr.)
<br />November 29, 2021
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