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<br />SEAL OF THE STATE OF NEBRASKA IT
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<br />"CERTIFIES 'THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY.FOR VITAL REC.:.QRDS
<br />DATE OF ISSUANCE
<br />UUaL2 ASK
<br />202401948
<br />la 13oi
<br />SARAH I3OHNENKAMP /
<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 DECEDENTS -NAME (First,
<br />Earl Henry $perSen
<br />Middle,
<br />4. CITY AND STATE OR TERRITORY, OR
<br />Grand Island, Nebraska
<br />7 SoCiA4SECURITYNUMBER
<br />6.07 '315206
<br />est,
<br />Suffix)
<br />FOREIGN COUNTRY OF BIRTH
<br />6a, AGE - Last Birthday
<br />(Yrs.)
<br />b. FACILITY -NAME (If not institution, give street and number)
<br />Atria. Health Broadwell
<br />DEATH (Include Zip Code)`
<br />Grand ISiend i5d803
<br />9a. RESIDENCE -STATE
<br />Nebraska::
<br />2
<br />'0
<br />d fTREET AND NUMBER
<br />2 2 S teak Street':
<br />9b. COUNTY
<br />Halt
<br />91
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ERJOu patient
<br />❑ DOA
<br />Oa. MARITAL STATUS AT TIME OF DEATH ® Married , 0 Never Married
<br />0 Married, but separated ❑Widowed 0 Divorced 0 Unknown
<br />tTHi*R l4lAMI
<br />Henry F ;'Bo
<br />iddie,
<br />Suffix)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS I MINS.
<br />3„ DATE OF *ma., bay, Vi
<br />OCtober 1 2021
<br />6. DATE OF BIRTH (Mo., Day,.Yr:)
<br />OTHER ® Nursing Hi
<br />❑ Decedent's IS
<br />❑ Other (Specify)
<br />sa' CITY OR TQ>l1IN QI
<br />Apri14, 19
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Donna J Ritter
<br />12 MOTHER`S•NAME (First, Middle,
<br />E{iza•' Kuhl
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) Yes 0006/1949-11/17/1952
<br />16.;METHODPFDISPOS.ITION
<br />Burial ❑ Donation
<br />❑: Crematio i ❑ Entombment
<br />❑ Removal ❑ tither (specify)
<br />14a. INFORMANT -NAME
<br />Donna J Boersen
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />1Ta;;FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livint9aton-Sondermann Funeral Home, 601 N. Webb Road, Grand Island,
<br />111. PART I. Enter
<br />respiratory ae
<br />18b. LICENSE NO.
<br />1439
<br />ebraska
<br />CITY / TOWN
<br />Grand Island
<br />Y
<br />LIMITS:'"
<br />14b. REI ATIC
<br />Spouse
<br />SHIP TO DEGE
<br />PIT :•
<br />TATE
<br />deka
<br />CAUSE OF DEATH (See instructionsi:and examples)
<br />chain of events- thsaeses, injuries, or complicationathat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />n, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add add tonal lines if neceese
<br />IMMEDIATE CAUSE:
<br />a) protein calorie malnutrition
<br />IMMEDIATE CAUSE (Final
<br />diaeasa or uondititin resnking`'.
<br />In distil)
<br />sequentially listc
<br />any,;leadine to the.
<br />oftt lea ,...
<br />di8ons, If.
<br />use listed
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />13) congestive heart failure
<br />Enter the EIN00.0049 C USE
<br />(Mee ase or injury.: that initiated
<br />the events resulting In death).'.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />136. +CCOde
<br />68803::
<br />APPROXIMATE INTERVAL
<br />Itadaath
<br />onset to death
<br />4 Years
<br />18 PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but no€ resulting in the underlying cause given in PART I.
<br />Coronary artery disease, liver abscess
<br />5-
<br />ALE::¢;
<br />regtiaxdvrhttfhpast year
<br />Preddant at t the of death:
<br />❑ Not pregranit, but pregnant within 42 days of death.
<br />❑ Not pregnant, but pregnant 43 days to I year before death
<br />raUnknown if.pregtlitd within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pendinginvestigation
<br />0Suicide Could not be determined
<br />21b. IF. TRANSPORTATION INJURY
<br />❑ Dn./Operator
<br />Passenger
<br />0 Pedestrian
<br />Other (Spec,
<br />)
<br />9. WAS>i9EDICAt- EXAMINErRCTsD
<br />OR CORONER CONTA? .:
<br />❑ YES Ii ND
<br />21c. WAS AN AUTO)
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YEs NO.
<br />220 DATE OF INJURY (Moi, Day, Yr.)
<br />�22d. I RY AT WORK?
<br />❑YES [] NO .
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY At home; farrtl, street, factory, office building, constn
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t;LOCAT itimoF €NJURY • STREET& NUMBER,.APT:NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 1, 2021
<br />23b. DATE SIGNED (Ma., Day, Yr.)
<br />dtdber 7 : 2021
<br />9d..Tnfhetmat of (try knowledge, death occurred at the time,date and place
<br />lend dud to thecauae(s) stated. (Signature and Title)
<br />Sara Graybill, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />08:47 AM
<br />25. DIP TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑YES (gi NO ;❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR ISSUE DO
<br />❑ YESEamp.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., D
<br />24e, On the basis of examination and/or tnvestiga ion, In
<br />•the t(iiia, date and place and due to the causes) stated.,;.
<br />ATION::BEEN CONSIDERED?
<br />21 .NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sara Graybili, Mb, 2116 W Faidley #400, Box 9802, Grand 'Stand; Nebraska,68803
<br />26b. WAS CONSENTGRANUth?
<br />Not Applicable If 28a Is NO ❑ YES:
<br />HO'
<br />28b. DATE MEOW REGISTRAR (Mo., 0
<br />October 11,;2021
<br />
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