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STATE OF NEBRASKA
<br />`'!rrll'llliNirl��` �rlr�pia�,aa
<br />�6G41II111llutt' �:
<br />tt4§'It`s,
<br />WHEN' , THIS ''::; COPY CARRIES THE RAISED SEAT : CF T E STATE OF NEBRASKA, tr.
<br />CERTIFIES THE DOCUMENT BELOW TO BEA TRUE COPY. OF • THE ORIGINAL RECORD :•
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH 1S' THE LEGAL DEPOSITORY FOR .VITAL RECORDS
<br />O T E OFF ISSUANCE 0 ++ RUSSELL FOSLER •
<br />202302227
<br />AND HUMAN SERVICES •
<br />STATE OF NEBRASKA • DEPARTMENT OF#HEALTIf AND #fUMAN SERVICES
<br />CERTIFICATE;<OF DEATH
<br />4/12/2019
<br />ASSISTANT STATE REGISTRAR
<br />LJNCDt11y NEBRASKA DEPARTMENT OF HEAL'T'H
<br />1. DECEDENTS•NAME (First, Middle, Last,
<br />Keith Richard Rolls
<br />x)
<br />4. C1TY?ANCI STATE ORTER1TORY, OR FOREIGN COUNTRY OF BIRTH
<br />Leroy/ Nebrask
<br />7. SOCIAL SECURITY NUMBER •
<br />.......;;..
<br />5a AGE..': LastBiliftday : UNDER1„YEAR
<br />:p Sb. FACILITY NAME (tf not IRstitutlon, glye street and number)
<br />CHF Health t. Fttncis
<br />A 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68.80,3
<br />9s: RESIDENT
<br />Nebr..asks
<br />ATE
<br />Ed. STREET AND`NUMBER
<br />715WJohn St
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2t 2019.
<br />s.DATEOIaRTlfr
<br />.:;.DAYS
<br />-Sa. PLACE OF DEATH
<br />HOSPITAL © inpatient
<br />l7)Qu m
<br />HOURS
<br />MINS.
<br />Sb. COUNTY
<br />Hall
<br />9s CrTYORTOWN;; •
<br />Gra�td:tst'attcl?
<br />0 Oth r (slur)
<br />6d. COUNTY t IF DEATH
<br />Hall
<br />Se. APT. NO.
<br />Sf. ZIP CODE
<br />68801
<br />t(Ia. MAfdTA . STATUS AT>ttME OF DEATH Married 0 Never Married
<br />❑ krarrted, flub separated 0 Widowed 0 Divorced 0 Unknown
<br />1Ub. NAME OPS :1
<br />►tadys R Karr
<br />Unix) if
<br />o. INS bE C17Y
<br />O No
<br />4:
<br />N.
<br />.6
<br />11. FATHER S•Nome (Fii sit, Middle, Last, Sufitx)
<br />Kenneth Roils
<br />1S :EVER IN U a: ARMED::FI
<br />uoi Flys. <
<br />ES? Give dates of service 0 Yes,
<br />18. M£THOD.OFDkSP€>SITION
<br />�j Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />12 MOTHERS -NAME (First Middle,
<br />Vera Mohlman
<br />14a. INFORMANT NAME;;,;
<br />Gladys Rolls
<br />16a. EMBALMER -SIGNATURE
<br />Stacie'L Ruiz
<br />16b O.
<br />LICENSE N
<br />1495
<br />16d. CEMETERY; CREMATORY OR OTHER LOCATION
<br />❑;tze rmoval ❑ Otho:( ecify) Cedarview Cemetery.
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town State)`
<br />All Faiths Funeral Horne. 2929 S. Locust Street, Grand Island, Nebraska
<br />CITY 1 TOWN
<br />Doniphan
<br />Sc. bATE (Mo
<br />Apr11,8, 22019
<br />G 4JSE OF DEATH (See instructldns.pnd examie8)
<br />awhile such.* garden arrest, •
<br />aria.: Add addkWml Iroise If eecresery. •
<br />PANTE ERM . thhahaM gtetents--aapnf, Inl Mas, or complk*Scm-that directly cauite th. death DF NCT ental »nnin
<br />reepinttdrlt anect or ventncuier fibrillation MUM.* eh eine the stiology. DO NOT ABBREVIATE Enter onty air carne on.
<br />IMMEDIATE CAUSE.
<br />a) Sudden Cardiac Death
<br />IMMEDIATE CAUSE {Final
<br />disease or .O1Giii3„ resukeig
<br />entaly ran eirnaldone' N
<br />y•te*dutg 1a tlae.;caua Ems:"
<br />1155,a.::::: ...... ......
<br />55 UNDERLVWO
<br />i# otia)uryt(f f 05*11
<br />a8uae g a, deeibl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE T
<br />d)
<br />OR AS A CONSEQUENCE OF:
<br />APPROXIMATE
<br />rota to ti Bleb
<br />Minutes.
<br />to
<br />1$. PART II. OTHER SIGNIFICANT CONDITIONS
<br />bating to the death but not resulting In the underlying eau
<br />19: WAS ME *CAI: EXAMINER`
<br />OR CORONER CONTACTED?
<br />0.W FEMALE
<br />0 Not pr.gnant within pat
<br />Fragment at time of death
<br />N°. VM!fgnaurt; Gut pretlniijn.wkhin 42 days otdeath
<br />❑ tMl pnrgnmt, kat D./0days td 1 year before
<br />de
<br />❑EiiakrWFtan 7p4mnt vAttaii4 tiro peat year
<br />221. DATE OF INJURY (Mo., Day, Yr.)
<br />2d INJURY`AT1NORIC?
<br />s N0
<br />t
<br />22r, LOCATION OF;INJURY S
<br />21a. MANNER OF BEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending I veatlgatlon
<br />0 Suicide ❑ Gaaid'iwt b0,04**,
<br />21ti IFTRANSPORTATION INJURY
<br />rrp*t� Drivertoperaror
<br />LJ
<br />0 Passenger
<br />pedeptdan
<br />❑ bthi :ISpecify)
<br />22b. 11ME
<br />INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, oMice bull
<br />Pte. DESCRIBE HOW INJURY OCCURRED
<br />#TE r:lt t1El'fH (Mo., Day,
<br />CITY/TOWN
<br />,con
<br />STATE
<br />24*.. DAT4SIGNED(Mo., arty, Va.
<br />AgriW'2D19 - •—.
<br />b. DATE SIGNED (Mo., Day, Yr.) 21c, TIME OF DEATH
<br />a. To the beet o1 my trwr iwledge, death occurred al the 1fiN, date andplace
<br />anddue tit:dm causehd seated. Pigahs TRI.)
<br />PRONOUNCED DEAD(
<br />April 2. 2019
<br />On thebests of.x'attnation andlorinvpapatlon, Italy op
<br />theMite, *Aland plebe and dub to the aasaa(al Blast Blignielfl.
<br />iltarrmette Gallagher, County MttorrteV
<br />DTOBACC I• USEVONTRIBUTE TO THE DEATH? 261. HAS ORGAN,OR TISSUE OONA'T*ON BE N CONSIDERED?T albT
<br />ID G
<br />YES NO Not ApplIcab a If Hefiat
<br />0 YES ❑ NO • 0 PROBABLY J UNKNOWN 1 0 IR)
<br />21. NAME,TITLE AND ADDRESS OF CERTIFI R (Typeor Print
<br />Wilitarnette Gatlagtier, County Attorney, 231 S Locust Street, Grrand:istand Nebraska;, 68801.
<br />281 3eolgRAR S SIGNAcTURE
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