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<br />° tit�a„lir dtSTATE OF NEBRASKA /\FI
<br />- �rG641'AiF' 11➢ddJ.r....4,irrrrmP,�� .....
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF PIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />"HUMAN SERVICES, V: rAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAVE O ISS(.ANCE
<br />1 /25/2024 `'
<br />LINCOLN, NEBRASKA
<br />202402640
<br />,34t4 44,114t7
<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 OECEDEN1 S NAME. (First, Middle, Last, Suffix)
<br />,:i1;,:foUti104.iMiedikiaetu Henry
<br />4.OITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />McCook, Nebraska
<br />7SOCIAL SE UR(TY"'NIIMBER
<br />50846-0 60.
<br />5L: AGE tet Birthdgy.
<br />(Yrs.)
<br />4'
<br />1
<br />I
<br />0.
<br />8b. FACfLUTY NAME (IT riot Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />c.:CrIY OR'TOWN CdF DEATH (Include Zip Code)
<br />(./arid Island 56.3
<br />IN. RESIDENCE -STATE
<br />Nebraska
<br />9d ;;8 REST AND rOliBER
<br />1::512 Church Rd :;<;
<br />9b. COUNTY
<br />Hall
<br />71..
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE O>= DEATH 'i:.
<br />i,F,HOEFITALqpIrtptitiont
<br />•E(•EIZ/Ou patient
<br />0 DOA
<br />ilei It)ARfTAI S'TA. US AT TIME OF DEATH ® Married ❑ Never Married
<br />, 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />11 FATTIER B-MAME (First, Middle, Last, Suffix)
<br />Starl#eY +lerrry ;'€
<br />1S ;:EVERIN 1;1 S ARMED`FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No •
<br />45. METHOD OF DISPOSITION
<br />Q Burial ❑ Oofretion
<br />Cremation 0 Entombment
<br />❑ Remove(;; ❑ Odra/ (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 00847
<br />3: DATE OF DEATH tMo., Day; Yr
<br />January 1.24
<br />6. DATEOFBIRTH(Mo DAy Yf.) ;t
<br />September 18,:.1952....:.:.
<br />OTHER 0 Nursing Home/LTC
<br />i
<br />❑ Decedent's Homo
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />lot . NAME OF SPOUSE {F(rat, Middle, Last,
<br />Kristin Mcdowell
<br />112, MOTHER`S-NAME (First, Middle,
<br />Jean C[ittenden
<br />1 Hoept a 11.aoltitjt
<br />{
<br />9f. ZIP CODE $9, INSIDgOi`f CYWi TS.,
<br />68801 >YES Qs -NCO
<br />Suffix) If wife, give maiden name ='
<br />14a INFORMANT'NANME•
<br />Kristin Henry
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />utrari Funeral Chapel, 3005 S. Locust St., Grand Island Nebraska:
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (Ser (nStrUOtioibs (&1tid examples)
<br />18. Flirt'I' I. Enter the child of events- -diseases, injuries, or compilcationsdhet directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reepkatery arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) myocardial infarction
<br />Maiden Surname)
<br />iMM,601A All CAuaE (Find
<br />diss'ses ar condition resultln
<br />Irt iiFseh4,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, K b)
<br />any, leading to the cause listed
<br />ortlitle s
<br />Entity the UNDEE.YINR CAUSE
<br />(djfss ;:at' li>juty that ditletfd
<br />the events resulting in death)
<br />LAST
<br />14b. RELATIONSHIP Til DECEi
<br />Wife
<br />16c- DATE (MO., Gey, Yr.). ,.,
<br />January16 2024
<br />STATE. .>
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />eneetto
<br />2 Ht
<br />onset to d eth •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 .:FART if, OT}hER etemeICANT CONDITIONS -Conditions contributing to the death but n
<br />20. IF FEMALE:
<br />Nos ptegnanf within past year
<br />}}'� Pregnant *t.:tiim of deati �
<br />blot p egna it bus Drepnsnt whMn 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant wlthtn the past year
<br />22L DATE AF INJURY{MIlo;3, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YE'S to NO ;
<br />21s. MANNER QF DEATH
<br />Natural ❑ Honir
<br />❑ Accident Frride
<br />Pertding Invesapatkrn
<br />0 Suicide
<br />0 Could not be defirmined ''
<br />iting,ffiith&itniderlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF NNJURY-At
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />229. LOCATION INJURY- STREET & NUMBER, APT.NO.
<br />23e. OATEOF.DEATH (Mo., Day, Yr.)
<br />January 12, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 15, 2024
<br />CIT :00We.
<br />23c. TIME OF DEATH
<br />03:51 PM
<br />230 TD;ihe bier ornijr knowledge, death occurred it the time, date and place
<br />.anddW M t e c useis) stated. (Signature and Title)
<br />Rebecca Steinke, MD
<br />21b. IF TRANSPORTATION INJURY
<br />,iii❑ Dnyer/Operetor
<br />feaasnger
<br />0:pedesrian
<br />❑ Other (Specify)
<br />onset to death.
<br />19. WAS:MEDICAl EX MINiR;.
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />29c. WAS AN AUTOPSY PERFORMI
<br />❑ YES ®NQ
<br />21d. WERE AUTOPSYNIND(NGS AVA.1LA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES [ NO
<br />home farm street, factory, office building, construction at
<br />STATE ;23PC
<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 />SSit.',OrrthSbeiris of examination and/or invsstigetlon. In my ojrWin asath ti �..
<br />Ila tribe date and place end due to the cause(.) stated. N eiid:'lttie) `<.
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES i J NO ;Q PROBABLY 0 UNKNOWN
<br />ii NAME, TITLE ANDD ADDRESS OF CERTIFIER (Type or Print
<br />Rebecca Stelnke'MD, 2116 W Faidley #400, Box 9802, Grand Island,: Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES{ NO
<br />26b. WAS CONSENT GRAND?::;
<br />Not Applicable if 280 is HO.
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR -0o., Day, Yr.)
<br />January 24, 2024
<br />CID
<br />
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