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<br />STATE OF NEBRASKA
<br />_>
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA„ IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OF.tSS.W Nc Ec
<br />4/812024
<br />NCOLN,NEBRASKA
<br />202401 S4
<br />SARAH BOI-1NENKAMP" f
<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 />E (First, Middle, Last, Suffix)
<br />Jaeger
<br />4. CITY AND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />DECEI?ENVSNAM
<br />Jeffrey Allan
<br />Grand (sign
<br />Nebraska
<br />? SOCIAL SECURITY NUMBER
<br />5t)i3 04.8421
<br />8b FACIIIJTY.NAME (N'rlot'Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />6a.AGE Last Birthday
<br />(Yrs.)
<br />55
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />24,{
<br />3. DATE OF DEATH IMo., Dim Y),,
<br />March 27, 2024
<br />Sc. UNDER I DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />:HOSPITAL 0Inpat)erit
<br />ER%Ou patient
<br />❑ DOA..
<br />9a RESiDENCE STATE
<br />Nebraska
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Horne/LTC
<br />❑ Decedent's
<br />❑ Other (Spec
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Sb. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Doniphan
<br />94f. STREETAN1 NUMBER
<br />200 W l3rlrtelt Aye
<br />IOa, MARtTAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S NAME_(Flrat, Middle,
<br />Allan Ray.. Jaeger
<br />13. El/ERIN U S, ARMED FORCES
<br />(Yea, No, or Unk.) No
<br />46 Mth'HOD OF DISPOstnON
<br />Q:Suriat [}Donation
<br />� Cremagtn} ❑ Entombment
<br />❑'RsfnovaI ❑'Other (Specify)
<br />Last, Suffix)
<br />Be. APT. NO.
<br />8f. ZIP CODE
<br />68832
<br />IOb NAME OF SPOUSE (ROE, Middle, Last, Suffix) If wife, give
<br />Claudia Lynn Waits
<br />Give dates of service If Yes.
<br />1 12 MOTHER'S -NAME (First, Middle, Maiden
<br />LaDonna Mae Sandoe
<br />don n
<br />�)NSi!QE I{ITY#.tM1'r:,9
<br />14a. INFORMANT -NAME
<br />Claudia Lynn Jaeger
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1
<br />i8E
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />18b. LICENSE NO.
<br />18c. DATE (Mk.l
<br />April 2, 202
<br />Di
<br />CITY I TOWN
<br />Gibbon
<br />17*.. FUNERAI.;$QME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral FOnerat Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />IL PART I. Entertht
<br />respiratory erre
<br />it
<br />CAUSE OF DEATH€(See.lnstruetlonsl and exampled
<br />(events- -diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ntdculer fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessery.
<br />EblATE DAUSE(
<br />dhle!!e ortoruutiori
<br />in death)
<br />saeu entalb list conditions, N ';
<br />any, *RAMP to thg cauea gated
<br />IMMEDIATE CAUSE:
<br />a) Pulmonary Thromboembolism
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Deep Vein Thrombosis
<br />Et UNDEtRLYMNGCAUSE
<br />(diti ase iN inierithat initiated'
<br />the ewms resulting in death) ...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />'18,'PARTAL.01RERSIGNORMNT CONDITIONS -Conditions contributing to the death but not
<br />Presumed Inherited TKrombophilia (Prothrombin gene mutation)
<br />0:IFaFEMALE
<br />riot Ptegn4et eilhin past year
<br />:Fregdsfa ettlilwr etdatit;
<br />❑ Not.Pregmml but Irregrent witlibt 41 days of death
<br />f❑- Net pregnant, but pregn nt43 Royal* t year before death
<br />..i.I,.Udknmm 1f.p sgn*M With n the path year
<br />221
<br />DA
<br />ERYIMp Day,Yr..
<br />RY AT WORK?
<br />YES 0 NO...
<br />22f LOCATIONi
<br />22e,
<br />21a. MANNER OF DEATH
<br />Natural
<br />0 Homicide
<br />❑ Accident endington
<br />0 Suicide 0 Peould not be deteInVatlgatrmined
<br />tilting in theuriderlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b, IF: TRANSPORTATION INJURY
<br />0 Driverioperator
<br />Passenger
<br />PfMatrian
<br />❑ Other (Specify)
<br />f8. WAS ME ICAL:EXAMI N
<br />OR CORONER STA
<br />OYES'
<br />21c. WAS AN AI lT
<br />® YES
<br />21d. WERE AUTOPSY PI
<br />TO COMPLETE
<br />® YES
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construct
<br />SCRIBE HOW INJURY OCCURRED
<br />INJURY'S STREET & NUMBER, APT.NO.
<br />i AVAIU B
<br />stow.::{
<br />CITY/TOWN:
<br />STATE
<br />35, DATE OF DEATH (Mo., Day, Yr.)
<br />March 27, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Acrel 1, ?0244 09:16 PM
<br />Tomo bO *ormy knowltdge,death occurred at the time, date and place
<br />ild that°OSbnuae(s) stated. (Signature and Title)
<br />lchelle P Elia, MD
<br />D1()TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />d YES :glNO ❑ PROBABLY ❑ UNKNOWN
<br />MIME AilD AD ESS OF CERTIFIER (Type or Print
<br />Michelle P Elieff, MD, 4840 F Street, Omaha, Nebraska, 68117
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />24e. On eye bjpib of examination and/or Investigation, In my oppi
<br />the tlmel'date and place and due to the causes) stated. (SIL
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES ❑ NO
<br />28e. REGISTRAR'S SIGNATURE
<br />it
<br />26b. WAS CONSENT GRA
<br />Not Applicable If 280 Is NO
<br />YES
<br />>rftP?4?YF:
<br />28b. DATE FILED BY REGISTRAR
<br />April 3, 2024
<br />. Yr.)
<br />
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