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oh STATE OF NEBRASKA
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<br />WHEN';TY!S COPVCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />.:; BE ATRUE COPY OF THE ORIGINAL RECORD ON FILE WITI+I ME NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />0,4TE OP!SSLM NCE
<br />211<5/2024
<br />LINCOLN, NEBRASKA
<br />G
<br />202401871
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />202401497
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 .FIECEDEN'#`S-NAME .(first, Middle, Last, Suffix)
<br />;Stephen Holbein Happold
<br />4: C1'I'Y IUJD;B7ATE bR"TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7`S004SEpuR1TY.NI.. MaER
<br />508 *2353
<br />8bifiACnLIN.NAMff:(If'tiot Institution, give street and number)
<br />1570 E. Ginner Road
<br />ec CITY OR'CbWN OPOEATH (Include Zip Code)
<br />Cion€phare 68832
<br />9a. RESiDENCE•STATE
<br />Nebraska
<br />9d411 rset I*D NUMBER
<br />;1570 E Giltner Road
<br />9b. COUNTY
<br />Hall
<br />Oaf _AGE - Last Birthday
<br />(Yrs.)
<br />81..
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />511:`P.LACE QF DEATO
<br />HOSPITAL ❑ fnpatient
<br />{l ERIOutpatient
<br />❑DOA
<br />ttia(MARITAL: STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'BeNAME (First, Middle, Last, Suffix)
<br />Norman V1 ikam.;; Happold
<br />13 .:EVER IN U S ARMED FORCES? Give dates of service If Yes.
<br />(Yes No, or Unk.) No
<br />18. METHOD OF a$POSITION
<br />Burial ❑ ppaiiEtion
<br />Cremation © Entombment
<br />❑ rtemo • Q Other (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />• 10b. NAME OF SPOUS
<br />Judith A Robb
<br />14a. INPORMANTNAME
<br />Judith A Happold
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />HOURS
<br />MINS.
<br />24 02024
<br />J. DATE OFATH o EI4ly, Yr.)
<br />February 2'024
<br />G. DATE OF Bliktlf (Mo,; DAA
<br />March 24;:.1942
<br />OTHER 0 Nursing Home/LTC
<br />® Dsc$dsnfa.Hosae...
<br />0 Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hail
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g INSIDECtTtrLIMIti
<br />YES ..111NO'
<br />(First, Middle, Last, Suffix) Ewife, give maiden name'
<br />12 MOTHER' -NAME (First, Middle, Maiden Surname)
<br />A(ice Ruth Holbein
<br />16b. LICENSE NO,
<br />1092
<br />t8d, CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />1Ta. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />Gibbon
<br />CAUSE OF DEATH (See:;lfSte:44 tiodta and examples)
<br />13. PART 1. Entii fhe chiiii of everts- -diseases, Injuria, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or vermicular flfriaatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 5 neaaary.
<br />IMMEDIATE CAUSE:
<br />a) metastatic lung cancer
<br />IMMafNATE OA}tea (f(r#at
<br />disease ar edlWkWrt {WI
<br />tiidiwtTrj::>
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />eequetxiaily list conditions, I b)
<br />any, leading to the cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entsr the UN0ER4YING C.A U$E c)
<br />(aluase or idi) that:iidtNtad
<br />ttt events resulting In doth) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART )i trtHERSIGNt1 iCANT CONDITIONS -Conditions contributing to the death
<br />hypertensit#t
<br />20. IF FEMALE;.
<br />Net Pre end wRhkt p#!•Ir.
<br />Pr000n„,tlmserdeliht
<br />N+yt prealypnt btd PntiptiInt within 42 days of death
<br />0 Not Pregnant, but pregnant 43 days tot year before death
<br />Unknown 12 pregnent wiMln the Pat Poor
<br />229 -:DATE OF►NJU
<br />N0,, Day, Yr.)
<br />22d. (NJURYAT WOFiIt4
<br />YES 0 NO
<br />21.. MANNER OF DEATH
<br />® Natural ©HdolFCidR
<br />❑ Accident ❑ending tnvestiyatlon
<br />0 Suicide ❑, CduId not be debnnined
<br />t not resulting in thti underlyIng cause given M PART 1.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJU
<br />22c DESCRIBE HOW INJURY OCCURRED
<br />22t LOCATION OF INJURY STREET R NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 8, 2024
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February. 2024 05:38 PM
<br />Tette bog army know edge, death occurred at the time, date and place
<br />RRnd **COSI* Causes) stated. (Signature and TRW)
<br />ChadVieth, MD
<br />25 DID TOBACCO USE CON TRI
<br />BUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION:BEEN CONSIDERED?
<br />YE$ :: NO "❑ PROBABLY
<br />Y.Atfi
<br />21.b. IF TRANSPORTATION INJURY
<br />❑ Diver/Operator
<br />:.: ❑ Passenger
<br />❑ Prdsatdsn
<br />0 Okher(Specify)
<br />14b, RELATION SNIP
<br />Spouse.
<br />:DECEDENT
<br />16e. DATE:,(Mo., pfty,
<br />Februia'ItIF
<br />APPROXIMATE INTERVAL
<br />onset to Nandi
<br />2 Months
<br />19. WAS MEIItL EXAMINER pi7
<br />OR CORONER CONTROTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY! RFORMEP
<br />❑ YES ®TIO
<br />21d. WERE AUTOPSY FiNDiNGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES CI,NO
<br />riii;aitreet, factory, office building, construction a t
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED OE .
<br />144.00 thC bssis of examination and/or instigation, aid my eelabn
<br />the tklN, dateand place and due to the cause(*) stated. ($lgi lturs Md'
<br />®UNKNOWN
<br />0 YES NO
<br />2T NAME, TITLE AND ARESS;6F CERTIFIER (Type or Print
<br />Chad Vitt► MD; 2116 W Faidley #400, Box 9802, Grand Island Nebraska 68843
<br />26b. WAS CONSENTGRANTED?......
<br />Not Applicable H 2$e is NO ❑YES
<br />2$a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr)
<br />February 14, 2024
<br />CO
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