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STATE OF NEBRASKA
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<br />WHEN 7"HIS DO PY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, orOimems THE DOCUMENT BELOW TO
<br />$,E A TRUE COPY Orz TIE ORIGINAL RECORD ON FILE WITH T IE NEBRASKA DEPARTMENT OF HEALTH AND
<br />``HUMAN SERWCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY`FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2/5/2Q24
<br />LINCOLN, NEBRASKA
<br />moms. 1. DECEDENTS NAME:(First, Middle, Last, Suffix)
<br />202403257
<br />SARAH BOHNENKA
<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 />14e1 •iTt :.13aorge.;Marx
<br />4 CITYAND S'I`ATEOR>.TERRITORY, OR FOREiG I COUNTRY OF 8111TH
<br />Herndon, Kansas
<br />f.,sOclAi,>8 CURi1
<br />908-244154
<br />NUMBER
<br />5a AGE Last ligrthdejr
<br />(Yrs.)
<br />82::
<br />1
<br />M:.
<br />8{i 'FACIUTYNIAME{(1not Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITYOR DOWNOF'OEATH (Include Zip Code)
<br />•Grand Island .68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a :PLACE OFDEATH ...
<br />HO8PItAL jtapatlent
<br />`❑ ER/Outpatient
<br />❑ DOA
<br />sd,,;BTREETAND NUM ER
<br />2809 Kingstan Cr
<br />190. /NAR TAf. STATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S NAME (First,
<br />Lewis (3 Marx
<br />9c. CITY OR TOWN
<br />Grand Island
<br />1t . NAME'OF SPOU8E (lairs
<br />Audrey Thomas
<br />2. SEX
<br />Male
<br />5e. UNDER 1 DAY
<br />HOURS MINS.
<br />11 00377
<br />3. DATE OF DirATF) (Mv Dtfy,y.r.)
<br />February 8, 2011
<br />(I. DATE Of BIRTi(::(Mo„ Day.?ir )
<br />September 26,1928-....:.
<br />ispice henl
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Speciry)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g opigo CITY:
<br />;YES . 0
<br />Middle, Last, Suffix) If wife, give tmiderl Hanna ?.
<br />Middle, Last, Suffix)..............12 MOTHER`S NAME (First, Middle, Maiden Surname).
<br />Frieda !mid
<br />13. E1fER fN US ARMEO'FORCES?
<br />(Yes, No, or Unit) No
<br />16. METHOD OF DISPOSITION
<br />Btttfal ❑ Dottfitlon
<br />Cm❑or t»nt
<br />0(Specify)
<br />Give dates of service If Yes.
<br />140 INPOiteANT-NAME
<br />Audrey Marx
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Sb. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATI0N CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />1Ta. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand island Nebraski
<br />CAUSE OF DEATH (Sea! Instructions an examples)
<br />1a. PART I. Enter tAPeMfn Of events- -0ianes, injuries, or compllcatioro.that directly caused the death. DO NOT anew terminal conte such as cardiac arraet,
<br />respiratory arrest, of ventricular fibrillation without slowing the stiotogy. DO NOT ABBREVIATE. Enter only one causal on a line. Add additional lines anecusary,
<br />IMMEDIATE CAUSE:
<br />IMMEOIATECAUSE(Flnal .:;:: a)Alzheimers Dementia Complications
<br />amuse or condiiicl waun'n
<br />kl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, H b)
<br />any, loading to the caum listed
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ep1014040t#.YINO, C)
<br />(doll$. or irt)utkthat ilYHiaNd
<br />Hie events meet" in dee" DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />18..PART If::O'THER $#GNIFICANT CONDITIONS -Conditions contributing to tile. dao
<br />20. IF FEMALE",
<br />N0 rgn*nttviglid pett'yser
<br />❑Prettsels at;tlla. rat doalh:
<br />i
<br />❑ preeM !i but jir$Mnt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown typysignant. wltMn the put year
<br />220 DATE;OF:(NJURY(I1164:Day, Yr.)
<br />22d. INJURY Ar WORK?
<br />OYES NO
<br />set i(.00
<br />1
<br />210. MANNER OF DEATH
<br />® Natural ❑ Horiileide
<br />0 Accident ❑ peaAMg rmreatieatwn
<br />❑ Suicide ❑Could not be datfminsd'
<br />put
<br />toting#t theunderlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21.b..,IF TRANSPORTATION INJURY
<br />❑ fol:!! /Operator
<br />❑ Pati ngar
<br />Psi sstrlan
<br />0 Other(Specify)
<br />0
<br />14b. REt.AT10N,$.tIP TCI D(:C NT
<br />Wife
<br />16c. DATE (Mo„ Day, Yr.),.:.:. ,/
<br />February ')2
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />weld todu$Eh
<br />5 Yeah
<br />onset to d6Mh
<br />19: WAS MEDICAL EXAMINER
<br />OR CORON RGONTAc1':ED?
<br />❑YES
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES IE No
<br />21d.WERE AUTOPs'u:I NGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YE$ ❑NO:. IIIc
<br />22c. PLACE OF INJURY.At Rolfe farm, street, factory, office building, construed
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OBOF IN Niki',;., STREET & NUMBER, APT.NO.
<br />23a. DATE Ott'DEATH (Mo., Day, Yr.)
<br />February 5, 2011
<br />CITY/TOWN.
<br />23b. DATE SIGNED (Mo., Day, TO 23c. TIME OF DEATH
<br />Febrrtart+7, 2011 10:50 AM
<br />22d
<br />tom* beat orit1 t knowIedge, death occurred at the time, date and place
<br />slid duelg RIOSeuu(e) stated. (Signature and TRIM
<br />Richard Friiehlino, MD
<br />u
<br />STATE
<br />24a. DA'rE SIGNED (Mo., Day, Yr.)
<br />($I
<br />24b. TIME OF DEATH..
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />;D
<br />2N.M Se beets of examination and/or Investigation, my,
<br />.,, His tins; dots and plan and due to the cauea(si.atated.
<br />26. DID TOBACCO USE CONTRI(3UTE TO THE DEATH?
<br />43 YE$ J NO ❑ PROBABLY 0 UNKNOWN
<br />27NAME/ TTT4R ANTS A1'ftESE OF CERTIFIER (Type or Print
<br />RiPbekd Fruehling; MD, 2116 W Faidley #400, Box 9802, Grand Island Nebraska, 68803
<br />Ma, REGIS
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />SIGNATURE, S
<br />26b. WAS CONSENTORA
<br />Not Applicable if 26a Is NO
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />February 8, 2011
<br />Cfl
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