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STATE OF NEBRASKA
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<br />WHEN 1-H15 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 rDEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ITE:.;OF I3iSUAltCE
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<br />11I1/2023''
<br />LINCOLN, NEBRASKA.
<br />202403257
<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 QF DEATH
<br />1 QEGEDENT::S-NAMgtFirat, Middle, Last, Suffix)
<br />44kudtaiill4eari Marx
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY QF BIRTH
<br />Hastings, Nebraska
<br />1,.$001A6 SECURITY Ni MBER
<br />i�05w36-85�9
<br />8th : FACILITYA&ME {it not Institution, give street and number)
<br />Tabitha At Williamsburg
<br />68. AGE - LastBudldar
<br />(Yrs.)
<br />91..
<br />8c;;GITy OR TDyIfN OF:DEATH (Include Zip Code)
<br />L rewire 68516
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d.: STREGT atm rliimAGR
<br />!:260WilKinOateirtCir
<br />16a MARITR4 STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated RI Widowed 0 Divorced ❑ Unknown
<br />9b. COUNTY
<br />Hall
<br />11 FATHER $-MAME (First, Middle, Last, Suffix)
<br />Charles ` 7'honiaa
<br />13 EVER IN U.S ARMED: FORCES? Give dates of service H Yes.
<br />(Yes, No or Unkj No
<br />w 16. METHOD OF DJSPOSrON
<br />.013.4.0:# ❑ C araban
<br />Jj Crernagota ❑Entombment
<br />Ranaovai ❑ Qtlte► (specify)
<br />6b> UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />81. PLACE 01" DEATH
<br />HOSPLTAL [Q inpatient
<br />Q ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />1Ob. NAME, OF SPOUSE
<br />HOURS
<br />MINS.
<br />3. DATE OF rtEATH (1N,16tay Yr.;
<br />October 1„"(,.,.:2023.;;::;
<br />C. DATE OF BIRI l {Mo., tlayi. r.)
<br />June 9,19.32;:::;;. >.......
<br />OTHER ® Nursing Homs/LTC .
<br />Q Decedent's Home
<br />❑ Other (Specify)
<br />(
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />6•. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Ice Fad
<br />sp�,8ttINS)1 LIM
<br />CITY ITS
<br />'Y$5 QNO.<
<br />ret, Middle, Last, Suffix) if wife, give maicjen name
<br />1 12 MOTHERS -NAME (First, Middle,
<br />Irene Saddler
<br />14a INFORMANT.NAME
<br />Douglas Marx
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Colonial Chapel Cremation Center
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />oionial Chapel Funeral Home, 5200 R Street. Lincoln, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Lincoln
<br />Maiden Sum
<br />a and examples)
<br />9. PART]. Entei hschatn'of events- -diseases, injuries, or compiications.hat directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />respiratory asst, or ventricular tbdlation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />MNEDtAtEaAUSE(Feta '.>. a) Cerebral Vascular Disease
<br />ell eeorconditlanresuk g
<br />0
<br />$t tkitidrtheUNDERL01NaCAU E
<br />`:.:� (diallsa;or lnj(Ufy hsttn6ter/d
<br />the events mewling in death)
<br />LAST
<br />13.PARTtI OTHE
<br />CAUSE OF DEATH (See:instrvctiorf
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />(!(=!CANT ONDITIONs-Conditions contributing to the death but noire
<br />IFFEMALE:
<br />NdkpregraiinwItbfnp**t Year
<br />Pnpnant uinine of Mefi:
<br />❑
<br />Nef pregmtiii but pretji int Within 42 days of death
<br />dr
<br />:.. ... Q Net pregnant, but Pregnant 43 days to 1 year before death
<br />Q Unknown l pregnant within the past year
<br />24:0ATE Of=1NJ14RY'tldvw Day, Yr.)
<br />E ▪ 22d. INJURY AT'WORK?
<br />DYES 0 N
<br />2 OF NJ
<br />Alt OCA: •
<br />21a. MANNER OF DEATH
<br />®Natural Q Homicide::
<br />Q Accident Q Pending bweallp pttpn
<br />Q Suicide Q Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />UFI1 . STREET & NUMBER, APT.NO.
<br />tktg in the underlying cause given in PART I.
<br />21b., IF TRANSPORTATION INJURY
<br />tklwr/Operator
<br />0 Pasfenger
<br />Padestnan
<br />0 Other (Spicily)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Soniec
<br />October 21 2023
<br />araTla
<br />Nebraska
<br />68504
<br />onset* death
<br />onsotto death
<br />it. WAS MEDICAL ExAfitlNEg.
<br />OR ooRolit .icoNTAt,1r1 D?
<br />YES [} 311.3
<br />21c. WAS AN AUTOPSY.PE,RFORMHD?
<br />❑ TES ® NO:.
<br />21d. WERE AUTOPSY FINDINVI AVAE.ABG
<br />TO COMPLETE CAUSEOF DEATH?
<br />Q YES 0:149
<br />some farm street, factory, office building, conetructlon d
<br />)
<br />23a.?DATE 'OF DEATH (Mo., Day, Yr.)
<br />October 17,n 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 20, 2023 12:15 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />.ofl h beg of<p*Itnowledge, Math occunod at the time, date end place
<br />taEdddu49049use(s) stated. (Signature and Title)
<br />Jarrtie R."Peters, APRN
<br />24b. TIME OF DEATH
<br />24d. TIME
<br />:On aha fields of examination and/or investigation, in my oi:41*w
<br />tale tlMd, tea and plan and due to the eawe(a) stated: Ilignaepri
<br />•
<br />ED
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONA11014 BEEN CONSIDERED?
<br />YES : 'SI NO :';Q PROBABLY 0 UNKNOWN 0 YES %i
<br />ME, Ttrr1E AND ADDRESS OP CERTIFIER (Type or Print
<br />smile R 'Peters 'APRN, PO Box 1227, Bellevue, Nebraska, 6800
<br />Sha. REGISTRAR'S SIGNA fUREt ,
<br />26b. WAS CONSENT GRAN
<br />Not Applicable If 26a Is NO
<br />i0
<br />28b. DATE FILED BY REGISTRAR
<br />October 20, 2023
<br />Yr.)
<br />
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