|
STATE OF NEBRASKA
<br />tut %1,1,1 as- es, e, wi°e a t t am e ': sitstAtWwat;,
<br />ova
<br />11rHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A TRUE CORYQF.T 4E ORIGINAL RECORD ON FILE WITH TTHE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN .SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/24/2024
<br />LINCOLN, NEBRASKA
<br />O
<br />202403862
<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 />1 !:DECEDENTS NAME ;(First, Middle, Last, Suffix)
<br />Margret :':Ann. Reters
<br />4. CITY AND'ST'ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Scotia,:. Nebraska
<br />T::80CIAL SECURITY N. UMBER.
<br />508'54,4829.
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany. Square Care Center
<br />8d :'CITY QR TOWN OFDEATH (include Zip Code)
<br />3rand tstand_ 68803
<br />9a.'RESIDENCE-STATE
<br />Nebraska
<br />ad. STREET AND NUMBER
<br />943 S. Kimball St.'
<br />9b. COUNTY
<br />Hall
<br />Se. AGE - Last Birthday
<br />(Yrs.)
<br />82 ..
<br />6b1JNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />B. PLACE OF DEATH
<br />HOSPITAL ❑ inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />1Oa, MARITAL STATUS AT TIME OF DEATH ] Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Horace Karre
<br />0
<br />al
<br />EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />Yes, No, or link.) No
<br />1$.JItETHOD„gp,:OF DISPO..ITION
<br />Burial (JDonation
<br />cremation } Entombment
<br />❑ Removal,' ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo Days Ya
<br />July 16, 2024,
<br />6. DATE OF BIRTH (Mo., Day, Yr:)'''
<br />January:5,'
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9e. APT. NO.
<br />piss fdsciI(ty
<br />9f, ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maidens
<br />LaVern Dean Peters
<br />8g, INSIDECfTY LIMITS
<br />®YEs ju.
<br />12 MOTHER`a-NAME (First, Middle, Maiden Surname)
<br />Monica . Smyth
<br />14a. INFORMANT -NAME
<br />LaVern Dean Peters
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17aY FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Cufran Funeral Chapel, 3005 S. Locust St., Grand Island. Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART I. Enter'. the chain ofevents- +diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory rarest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUSE(Fhtel a)Severeprotein-calorie malnutrition
<br />disease et condition resulting.
<br />14b. RELATIONSHIP TCJ DECEDENT
<br />Spouse.
<br />16c, oAT{Mo„ Days
<br />Julv 17 x£)24
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Net conditions, if b)
<br />any; lsadirig tO the cases gpted
<br />sauna
<br />triter theUNOERLYING CAu8E
<br />(disease or injury that initiated
<br />the events resuki
<br />LAST
<br />ng in
<br />death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE, TO, OR AS A CONSEQUENCE OF:
<br />d);,
<br />IS. PART IL omen SIi;NIFICANT CONDITIONS -Conditions contributing to the death but
<br />Breast cancer, type 2 diabetes mellitus
<br />20IF FEMALE.;
<br />Ndtlh'egAaht w)th)h ppsl,year:
<br />C. Pragfeilt#t hits death
<br />Not eminent, but Pregnant within 42 days of death
<br />0 Not pregnant, but pregneft 43 days to 1 year before death
<br />❑„ Unknown it pregnant within the past .year.
<br />T2s,' OA1
<br />OPINJURY;(MO., Day, Yr.)
<br />22C INJURY AT WORK?
<br />Q YES ❑ NO
<br />21a MANNER OF DEATH
<br />® Natural ❑ Roadside
<br />0 Accident Panding investigation
<br />❑ Suicide ❑ Could not be determined
<br />STATE
<br />Nebraska
<br />17b. 2ipCoid
<br />688(;1
<br />APPROXIMAT_
<br />onsettodaatft >:
<br />Months
<br />IAL
<br />Ing in the underlying cause given in PART I,
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ oinveriOperetor
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES ®NO
<br />21c. WAS AN AUTOPSY PERRip:
<br />❑ YES NO
<br />D/'
<br />21d. WERE AUTOPSY FINDINGS AVAILAB1.E
<br />TO COMPLETECAUSE OF DEATH?
<br />El TES 0 N
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction sitj, l
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TION OF.NJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Jul' 16, 2024
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />401V .:.17; 2024
<br />3d.-Tt)4he bestetoly knowledge, death occurred at the time, date and place
<br />Intl dup ip the Cauae(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />09:25 PM
<br />I
<br />•
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />pi
<br />T
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TINIE'i
<br />24d. TIME PROPAOUNCED' I
<br />4e Onthe.basis of examination and/or investigation, In my opinion gaol
<br />-. Ste time, date and place and due to the causes) elated, (Signetuni anti
<br />26' fl)p TOBACCO uSEGONTRIBUTE TO THE DEATH?
<br />YES .':❑ NO ,:❑ PROBABLY ® UNKNOWN
<br />27 NAME Ma 04:ADDRESS OF CERTIFIER (Type or Print
<br />Chad Wath, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska,' 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES NO
<br />26b. WAS CONSENTGRI /ATE
<br />Not Applicable if 26a is NO
<br />28b. DATE FILED BY R
<br />July 23, 2024
<br />
|