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_.. __. STATE Q.F. NEBRASKA
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<br />t1/HEN THis CtPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERT/FIES THE DOCUMENT BELOW TO
<br />BEA ;TRUE COPY O THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ;DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES,' VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />rsiteqssomcs
<br />7/2W2024
<br />LINCOLN, NEBRASKA
<br />202403690
<br />SARAH BOHNENKAAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />•t: DEGEDENT!S-NAME .(First, Middle, Last, Suffix)
<br />Jeanif e': Lauise Brunken
<br />CERTIFICATE OF DEATH
<br />4 'CITYANIi, STATEGit TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />>,Deniphan, Nebraska
<br />Z 3bGIAL'$ECUiI:Fr.Y I
<br />50640 3 57
<br />UMBER
<br />8b. PACILITY..NAME` s not institution, give street and number)
<br />:Grand 1siand.;Roulenal Medical Center
<br />8 -crry orOfeyq pc DEATH (Include Zip Code)
<br />Grslwd island 68803
<br />9a. RE$IDENCE•$TATE
<br />Nebraska
<br />siu 3t . EETA +1D Nt$SeeR
<br />20$ E Plurtt St
<br />9b. COUNTY
<br />Hall
<br />5ei'AGE - Last- Birthday
<br />(Yrs.)
<br />95
<br />'5b, :UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL tgj Inpatient OTHER 0 Nursing Hom.ILTC
<br />0 ER/Outpatient Decedent's Nome
<br />0 Other (Specify)
<br />DAYS
<br />HOURS
<br />MINS.
<br />3: PATE OF;DEAS}(;Mp, DayFYr;
<br />Jun$ -21, 2024 .... ..;::
<br />6. DATE OF Bft'I li (Mo , Gejr. Yr.)•
<br />June kiln,/
<br />Q DOA
<br />110: t6ARRAL.STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11 ;FATHER'S NAME (FIrst. Middle, Last, Suffix)
<br />GetotQe ;William ;'.Weavers
<br />13.BVER IN U$ ARMEDFORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15,.METHOD OF Dtsrper eN
<br />Buhat [ Danation
<br />(tr-t Crematton Q Entornbmktt
<br />LJ Removat' Q tither (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />Heeptcs WOW
<br />88 i tSIDE CIMI1NtT$
<br />ns <N0;
<br />• 1Ob. NAME OF SPOUSE'(First, Middle, Last, Suffix) If wife, give mdsti n'tsiis
<br />l12. MOTHER'S -NAME (First, Middle,
<br />Margaret B Goesch
<br />14a. INFORMANTNAME
<br />Scott Roach'
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />17p;:FUNERAL:HOME:MAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All i=aiths;Puneral,1-lome, 2929 S. Locust Street, Grand !eland,- Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Doniphan
<br />CAUSE OF DEATH (see instructions and examples)
<br />is. PART I, Enter the chain*? events. .diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal awntesuch as cardiac arrest,
<br />rbsplratoy arrest, or ventltular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) cardiopulmonary arrest
<br />Ramos
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) ST elevation myocardial infarction
<br />Sequoweit v NW conditione,11
<br />*fly:zMeding to die causs,astad
<br />SntsrtMsU.I ERLY1NI CAUSE
<br />(dlss*sb or hilly thlit ff ldsted
<br />the events resulting In duth)
<br />LAST
<br />18. PART II
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUETO, OR AS A CONSEQUENCE OF:
<br />d)
<br />WYHEIi SiGNIFIGANT CONDITIONS-Conditiond contributing to ti
<br />IF:FEMAI.Er:
<br />'i�
<br />tin 0.0000
<br />deaths
<br />Not Pragtl►at, b4pie9Mntwithin 42 days of death
<br />.Not pregnant, but pregnant 43 days tot year before death
<br />:U nknown:;H:Prapnatn:!wlth1nnhs put year
<br />DAIS Os INJIJRY (lint., Day. Yr.)
<br />22d. INJURY AT WORK?
<br />�-[ YES::. s0.NO:...... .
<br />22 .i.ciatitift(* f
<br />UR
<br />death but r pt r4su1ting In the underlying cause given in PART 1.
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident Q Pending Investlpiuson
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />June 21, 2024.
<br />23b.,DATE,$JGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />11:29 AM
<br />, ..i y tmowtdga, death occurred at the time, date and place
<br />t: t re curse(*) stated. (Signature and Title)
<br />Ryan !) Nielsen, PA
<br />21b. IF TRANSPORTATION INJURY
<br />QDover/Operator
<br />0 Passenger
<br />© Pedestrian
<br />❑ Other (Specify)
<br />14b. RELAT OMHI•P TO.ECEDENt
<br />tirandSon
<br />1$c. DATE ;(Mo.,;:01W, Yr,
<br />June 27, 2024
<br />STATE..•
<br />,'.:''
<br />'14
<br />ebraska
<br />(p
<br />68801..
<br />:Otteetto deattl
<br />6/20/24:78/21/24
<br />19: WAS MAI. EXAMINER
<br />Oft doadii0 CONTACTED?.
<br />®YES Q NO. ,
<br />21c. WAS ANAU'POPSY'RERFCRllAEi
<br />0 YEs1 ill I
<br />21d. WERE CUTOP$Y'FINDINtii$ A BLE
<br />TO COMPLS rE CAU$E OF DEA :. .
<br />❑ YES
<br />me, farrn,•Ntreet, factory, office building, construction 's)te, slti
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24& TIME
<br />24.On the #iasis of examination and/or Investigation, In my
<br />She: time, data and place and due to the cau e(s) s
<br />26:tR:TOaAOGO USE CONTRIBUTE TO THE DEATH?
<br />Li Y$S NOPROBABLY ® UNKNOWN
<br />SOF CERTIFIER (Type or Print
<br />l yen 0 4leiaeri; PA, 3533 Prairieview St, Grand Island, Nebraska, 68803
<br />28a;REGISTRAR'S SIGNATURE A_ e
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES IFiJ NO
<br />;w?D
<br />tceittrad-N :<
<br />28b. WAS CONE'
<br />Not Applicable if 260'
<br />28b. DATE FILED BY REGISTRAR
<br />July 19, 2024
<br />Yr.)
<br />
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