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STATE OF NEBRASKA -3 A
<br />WHEN THIS COPY4ARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OFOIE ORIGINAL RECORD ON FILE win( THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICEE, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEIQF ISSUANCE
<br />,]0
<br />4/20/2024.
<br />LINCOLN, NEBRASKA
<br />2O2:4O2297i.. 384.tiebeil;,
<br />S,RAH11,,HNENKAMP
<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 />24 05581
<br />t Middle, Last, Suffix)
<br />1. DECEDENT'S -NAM -
<br />g
<br />Jack Howard Beckmann
<br />2. SEX
<br />Male
<br />3. DATE OFI3E01:iNcti.i.i.pay;Ir.)-giM.
<br />Aprit22,2024
<br />4:CITY/MD:STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7.40tIOt SECURITY NUMBER
<br />508-56 6256
<br />ea, AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />ii&i:FAOLIMNAMEIWitOt institution, give street and number)
<br />CHI Health St. Francis
<br />tWOnkrokTOWN,t3F,osATH (Include Zip Code)
<br />GranOleltindS8803
<br />Ea. RESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />DEATH:go
<br />:NlriosarrAit4IsI•s,:iposont
<br />••••'•'•'•••••• ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />6. DATE OF MOW
<br />June 12;41)49.,- • :8:*•..1-
<br />OTHER 0 Nursing Homo/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />lad. COUNTY OF DEATH
<br />Hall
<br />IJ Hospice Facility
<br />sdArsesixpe tOppsn
<br />.g.S13.,V4Paildt Head
<br />10644ARIT4 OTAlpsAT 'nee OF DEATH J Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />,9e. APT. NO.
<br />oil.ffisib.gyoremmot
<br />W. ZIP CODE
<br />68801 DYES NO
<br />10b. NAME OF SPOUSE•(ifirst, Middle, Last, Suffix) If wife, give maiden riWittr.
<br />Karen McLellan
<br />11.,EATHERI4AME:lerst, Middle, Last, Suffix)
<br />Howard Auqust Beckmann
<br />13 EVER IN 4J 5, iiiikii.0ORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />I12,60TtlitS.NAME (First Middle, Maiden Surname)
<br />Anita Sb�hine Ahrens , :•••••
<br />14a. INFORMANT.NAME
<br />Karen Beckmann
<br />15. METHOD OF DISPOSITION
<br />0:i4.40210n
<br />Crematton 0 En00ibmont
<br />adeWi (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP ittacsotort
<br />Spouse n;
<br />leo. DATE OP*.
<br />April 23 2024
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY/TOWN
<br />Gibbon
<br />Nebraska .•
<br />17a. FUNERAL Home NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All 2929 S. Locust Street Grand ISIOnct:.•Nebtatk4..,,
<br />CAUSE OF DEATH (See..111Struction8 :and examples)
<br />le. leAftti. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add ideational lines if necessary.
<br />IMMEDIATE CAUSE:
<br />pometeeTkoi,d08 (Fine) a) Pulseless electrical activity
<br />tams. or condition resiilting
<br />deelh) >DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially tat conditions, if
<br />any, !fading to the cause listed
<br />b) Severe metabolic acidosis
<br />APPROE1MA
<br />esteetlo. .
<br />INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />iiiiMthetititi6ekWitdpsi/Se C) Cardiogenic shock
<br />(diiiewerinjektnattnigned
<br />the events rostrithlig In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)Pulmonary embolism
<br />.itr;!!porpoct.li*art.MPOIPICANT CONDITIONS -Conditions contributing tolisdeath.bat nofreetitting In this underlying cause given In PART I.
<br />End,S*Ie OntalPiSease, respiratory failure, chronic obstructive lung disease, hypertention, hyperlipidemia
<br />• Onset ISSdetith•
<br />UnknoWn
<br />ortaixo*40,
<br />UnknoWn"
<br />. :
<br />onset death
<br />Unknown..................:
<br />inuts.mtb.14 0,40$1'.401_
<br />OR COR06(EitCONTAOTEOT
<br />IVES a No
<br />20.IF FEMALE:
<br />cr(Seti:r:!1past year
<br />O
<br />ii0f001440 within 42 days deh
<br />it;, but pregnant 43
<br />days 101 year before death
<br />if year
<br />0 Not Preen,regnentT."2"" Past
<br />known
<br />225 DATE Yr.)
<br />22d. INJURY Ar WORK?
<br />DYES ONO
<br />21a. MANNER OF DEATH
<br />12 Natural Q ***ids
<br />0 Accident 0 Pabding Wastig
<br />0 Suicide 0 Conic! not be ditel*bn
<br />rmlined
<br />22b. TIME OF INJURY
<br />210.::IF.TRANSPORTATION INJURY
<br />OngerfOperator
<br />Paaaenger
<br />:
<br />OPedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY- PER
<br />YES • • .EtrioliF
<br />21d. WERE AUTOPSY*AVATIABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES C1-10
<br />22c. ptxpooFNuRy4trioftwifOil'Oreet, factory, office building, constructiortehe,"#0149.0. •
<br />• • "Q;:0P,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2V LOCATION INJURY STREET & NUMBER, APT NO
<br />' Mg flgAr
<br />23a. DATE OF DEATH ;Mo., Day, Yr.)
<br />April 22, 2024
<br />CITY/TOWN'
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Abel ga.2024
<br />re, -ra-rantsee O* * thy knowledge, death occurred at the time, date and place •,:, , ...:]•i•
<br />,,',' *Ritittak*RieCatiSe(s) stated. (Signature and Title)EZeearil(hahid.
<br />Zeashan Khalid, MD
<br />23c. TIME OF DEATH
<br />01:58 PM
<br />orppaApco USE CONTRIBUTE TO THE DEATH?
<br />PROBABLY 10 UNKNOWN
<br />STATE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED
<br />• '4":-
<br />Orlf,thc beefs of examination andlor investigstan, in my amnion (leiefitOttitysttM::
<br />themes date and place end due to the eau a(s) stated. (skewers ootot(e).
<br />""• """ •••••••
<br />• •
<br />•
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES NO
<br />tNANtkiTITLBAND:ADOPESS OF CERTIFIER (Type or Print
<br />:•
<br />OAS -NW 01611(t MD, 2620 W Faidley Ave, Grand Island, Nebraska 68803
<br />285. REGISTRAR'S SIGNATURE
<br />6t4.41---11 81t1 --A-4/1.44".•
<br />26b. WAS CONSENT
<br />Not Applicable if 26a is NO
<br />28b. DATE FILED BY REGISTRAFTIMo.; Day; Yr.)
<br />April 24, 2024 • 'gi:;$1,
<br />(A)
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