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<br />)�,y?, " ftttitt#➢ 1/Q/ �ll�'ir\ AiMdJJJSTATE. OF N $RAS
<br />/rL3..
<br />+f4Rrd6l6iTlrth�@itlpek Y16M1MJJd�k x +f<Y666rA1'1'�IA16���
<br />;WHEN 'HIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CER77F`IES THE DOCUMENT BELOW TO
<br />;BE A TRUE COPY OF TILE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERV ICES,' VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS
<br />DATE OF ISSUANCE
<br />6/27/2024`
<br />LINCOLN, NEBRASKA
<br />d
<br />S J
<br />rr
<br />3,44
<br />(� n /� SARAH BOHNENKAMP
<br />2 ... Q A DEPAR MENT OF HEALTH R
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />I. DEMENT'S NArME (f irst, Middle, Last, Suffix)
<br />Geraldine. Marie > Stelk
<br />4. CITY AND STATE'OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings;: Nebraska
<br />7 :SOCIAL SECURITY NUMBER
<br />506-68-1187
<br />St AGE - Laat;Birthda l
<br />(Yrs.)
<br />8b. FACIUTY=NAME Of not Institution, give street and number)
<br />CH#.:Health St,::Francis
<br />8c CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 88803
<br />9a. RESIDENCE -STATE
<br />' Nebraska
<br />9d STREET PiND NUMBER
<br />404:404:1.4ftibtliatIdpfx
<br />9b. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PEACE c DEATH ::
<br />HOSPITAL ninpviont
<br />ER/Ou patient
<br />❑ o0A
<br />1011. MARITAL STATUS AT TIME OF DEATH ® Married W Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />1 V:FATHER S3NUME OM, Middle, Last, Suffix)
<br />Henry HapDold
<br />13 EVER IN Us3. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Link.) No
<br />15,.M.ETHOD;OF DISPOSITION
<br />ButIel Ca.bisioon
<br />Q Crematlotl Q Entombment
<br />❑ Removal'[pother (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF OE 1TH (ir.s.,0MYtVt.
<br />June 9, 2024
<br />8. DATE OF BIRTH (Mo: Day :' r.)
<br />February 21, _1937
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedsnrs Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />pe. APT. NO.
<br />55
<br />91. ZIP CODE
<br />68801
<br />Q.Ho pica Fec3IIty
<br />)4Watt Crrl` Ltfiele
<br />yeC
<br />1.Ob. NAME OF SPOUSE (Mit, Middle, Last, Suffix) If wife, give maiden name'
<br />Arthur Stelk
<br />14a. INFORMANT -NAME
<br />Arthur Stelk
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER $-NAME (First, Middle,
<br />Ruth Klndig
<br />18b. LICENSE NO.
<br />1495•
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />17a >FUNERAL::HOME NAME AND MAILING ADDRESS (Street, City or Town, Stere)
<br />All Faiths Funerat;Home, 2929 S. Locust Street, Grand Island,;Nebrastea
<br />CAUSE OF DEATH (See .linstrutthrlls and examples)
<br />Maiden Surname),;
<br />11. PART I. 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 line. Add additional Imes If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) cardiac arrest
<br />dt us oreondMonlasulUn
<br />In death)
<br />Sequentially list conditions, N
<br />erw0aeding tithe cauls listed
<br />BilleritneUNtiERLYlNtp CAUSE
<br />(ddsaeaa or Injuiy that iiiitdated
<br />Inc events resulting in death(
<br />,LAST
<br />18:;PART II. OTHER$1
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)respiratory arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) lifelong medical comorbidities, diabetes, Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />FICANT CONDITIONS -Conditions contributing to the death but mit result
<br />20 IF FEMAL E
<br />Nelthsanatitw(thdn paet�yesr
<br />Q Pregnantata#desih
<br />0 Not ..aiuH bttt pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Q unknown itpresntnt:wfthin the pelt year
<br />221 DAT
<br />OF 3NJURr (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />CI YES ONO:::;:..
<br />21a. MANNER OF DEATH
<br />Natural Q %Irises.
<br />❑ Accident 0 Pending InWetlg Jnon
<br />0 Suicide 0 Could not be determined
<br />ti
<br />underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f: LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 9, 2024
<br />23b..DAT£S)GN£D (Mo., Day, Yr.)
<br />; 121143:24',1024
<br />CITYITOVIIN
<br />23c. TIME OF DEATH
<br />11:00 AM
<br />2:1b. IF TRANSPORTATION INJURY
<br />O Od vst/Opsrator
<br />O paaasnger
<br />❑ Pedestrian
<br />❑ OtMalspecIfy)
<br />1411. RELATI
<br />Spouse
<br />1$c. DATE4910., 0sy, Yt.)
<br />June 13 2024
<br />19b. ZIgt Cads'.;
<br />68801..
<br />APPROXIMATE INTERVAL C
<br />ons9tt4/
<br />10 M)nutes
<br />ane•t.to death
<br />10 Minutes
<br />onset9 dsath�.
<br />Years
<br />omit lo death
<br />19: WAS MEDICAL
<br />OR COROta* corer T£D?`'
<br />® YES -.[� NO
<br />210. WAS AN AUTO -FEY PERPORNM'D?
<br />Q YES. N'
<br />21d. WERE AUTOPEYPINQ,NGS AYAtLABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />Q YEs O NO
<br />JURY -At home; larm :street, factory, office building, construct10n Nt4, *
<br />F2d To th. beet of my knowledge, death occurred at the time, date and place
<br />.04 due tdtlda causes) Witted. (Signature and Title)
<br />Robert Tambone, MO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />24d.
<br />2M_ Gfn Inc besq of examination anther investigation, kl aryl
<br />the fkile, sats and place and due to the esuse(s) meted.
<br />OR TISSUE DONATION:BEEN CONSIDERED?
<br />®NO
<br />2T IxiAf8E, TIT#(ANDAODl ES$ OF CERTIFIER (Type or Print
<br />`Robert Tarnbt)ne, MD; 2620 W Faidley Ave, Grand Island, Nebraska; 68803
<br />28.;DI0.TOBACCO U$E:CONTRIBUTE TO THE DEATH?
<br />Y£S .:I NO 7❑ PROBABLY 0 UNKNOWN
<br />29a. REGISTRAR'S SIGNATURE;
<br />glia. HAS ORGAN
<br />0 YES
<br />46.a.1./t.A.rz s t
<br />26b.WASC
<br />Not Applicable if 2M le
<br />OF DEATH
<br />D
<br />28b. DATE FILED BY REGI$
<br />June 25, 2024
<br />(140;Day,. Dsy Yr,)
<br />
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