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STATE. OF .NEBRASKA.
<br />?�f Fai66Vi�iWWMra�_��E�61;St.(A?�:x'`�itiwrryrpp,as� «._...
<br />EN MIS 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 , DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE O ISSUANCE:
<br />$123=2024
<br />LINCOLN, NEBRASKA
<br />4; DECEDENTD4IAME (FIYiat, 'Middle, Last, Suffix)
<br />Alma Rae € HDrak
<br />36t4
<br />RAH BOHNENKAMP
<br />2
<br />► h 9,; 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 />4. CITY "AND STA(TE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dee.Moines, Iowa
<br />7 St'OALSECURITVNUM81`R
<br />485-344462
<br />5a. AGE - Last Birthday`
<br />(Yrs.)
<br />v8 ` 8b. FACILITY -NAME (Isnot Institution; give street and number)
<br />Grand Island. Reoianal Medical Center
<br />8c. CITY OR 7Q!%Y i FL1EA'i 1(Include Zip Code)
<br />f3ra:nd Isla s€ 68803'
<br />9a RESIDENCE -STATE
<br />.. Nebraska .::.
<br />9d STREET ANO NUMBER
<br />4240 a Prairie Road
<br />9b. COUNTY
<br />Hall
<br />toe. MA R..AL 8TATU8 AT TIME OF DEATH El Married 0 Never Married
<br />g0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 fA 1HE#i $ AME (First'::: Middle, Lest, Suffix)
<br />R ymand Imes
<br />85
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />led. COUNTY OF DEATH
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MINS.
<br />HOURS
<br />22.02542.;.
<br />3. DATE OF DEAII. Mo , L(ay Yr j
<br />February'10,;:2022
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9i0INSIDE Ci PY UIMIT'S : is
<br />s13. EVER IN U S, ARMEDFORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />16 METHOD OF DISPOS1.110N
<br />I•
<br />I ]
<br />}„J Burlat ❑ l3Anlrtton:
<br />t tematton 0 Entombment
<br />0 Removal tither (Specify)
<br />10b:`NAME OF SPOUSE (First; Middle, Last, Suffix) If wife, give maiden name
<br />Maurice Horak
<br />14a. INFORMANT -NAME
<br />Maurice Horak
<br />165. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leona Robnet
<br />161,. LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />o. f pissaL HOME NAME: AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran 1=unaral Chatel, 3005 S. Locust St., Grand Island, Nebraska
<br />• CAUSE OF DEATH (See instructions' and examples)
<br />It. PART I. Enter the chain of events- .di:eerie, 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 lines If necessary.
<br />IMMEDIATE CAUSE:
<br />M1MEGIA TE CArtF�tlMd : a)Cardiogenic Shock
<br />duel jte;.or 4lydgiatkteek
<br />dertti} "
<br />Sequentially list conditions, if
<br />ski
<br />•u
<br />1
<br />Emri l► t UNDiERL ..10 f5,AU8E
<br />(dkeese tir injury t85t initIufMd
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Myocardial Infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c} Coronary Artery Disease
<br />the events resulting in death/ DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART 1i OTHEIR S(GNiFIGANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Diabetes Hypertensiori, Peripheral Vascular Disease s/p stents, Squamous Cell Carcinoma of the skin, Depression,
<br />Hyperlipidemia, 11/0 DVT, Carotid Artery Stenosis, Right brachiocephalic artery stenosis
<br />d IF FEMALE
<br />tJ NuPiIinelttVgttldn04t/1*
<br />❑ Pi�naii# nderin
<br />❑ Not pregnant, but pregdint within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before Math
<br />I Unknown ti prbgriarlt M9dmn rte Past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />21b.:)F TRANSPORTATION INJURY'
<br />❑>OrfverfOperator
<br />❑: Paesonger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo;Day, Yr,)
<br />February
<br />87ATe
<br />Nebraska
<br />APPROXIMA'
<br />onssttu:li
<br />Hours`
<br />onset to death
<br />Hours,
<br />onset'st
<br />Wears
<br />onset to (kWh
<br />19. was sisoit4ibtarilNE
<br />OR CORONER /CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?;
<br />❑YES EaNt}.::
<br />21d. WERE AUTOPSY FINDINGS AVAItABL
<br />TO COMPLE'T'E CAUSE OF DEATH?
<br />❑ YES O:CiiQ.
<br />TRY -At home, farm, street, factory, office building, construction alta, c
<br />LOCATION
<br />OFiDIAIRUSTREET d. NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH 010., Day, Yr.)
<br />February 10, 2022
<br />:tab. DATE. SIGNED (Mo., Day, Yr.)
<br />DTD T
<br />4
<br />STATE
<br />23c. TIME OF DEATH
<br />05:00 AM
<br />SibToRlblisefefrOiiibinviedge, death occurred at the time, date and place
<br />anti tills tatiwceilse(s) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PI
<br />24e. On the basis of examination and/or Investigation, in MY optM0Sdeam agci#„
<br />thetime, date and place and due to the cause(e) stated. (Slipatdre n6:Tltlir)
<br />78AOQO(lSE:Gi7M7RiBUTE TO THE DEATH? GeAN
<br />$ 4 WQ PROBABLY 0 UNKNOWN
<br />'#I`('I:e A oAO ESS OF CERTIFIER (Type or Print
<br />KimborlyA.Mick. is, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS OR
<br />0 YES
<br />OR TISSUE DONATION BEEN. CONSIDERED?
<br />®NO
<br />2811. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26e is NO. ti ' $
<br />28b. DATE FILED BY REGISTRAR(:
<br />February 18, 2022
<br />Yr:
<br />
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