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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL .RECORDS
<br />DATE OFISSUANC
<br />...............................
<br />....................................
<br />3/26/2o1
<br />202404260
<br />' ..) d 16474
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAI
<br />DEPARTMENT OF HEALTH'`
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 <DECEDENVS NAME#First, Middle, Last, Suffix)
<br />DUaf e . i rncId . owgr
<br />CERTIFICATE OF DEATH
<br />2. SEX
<br />Male
<br />4.4ITYAND:
<br />ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fremont, Nebraska
<br />7 <S:OCtAL SEc. Rm: NuMBER
<br />507464540
<br />5e. AGE - Last Birthday
<br />(Yrs.)
<br />71
<br />813. FACtLITYYNAME (Helot Institution, give street and number)
<br />2104 College Street
<br />Sc CITY OR TOWN OF.PEATH (Include ZIP Code) ,
<br />fraud Island 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0llinpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo Dap Yr.);
<br />March 17, 2021
<br />6. DATE OF BIRTH (Mo, Day; Yr.)'';;
<br />OTHER 0 Nursing Home/LTC
<br />IJ Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />}ios pace FaeiIity
<br />9d::STREET AND NU148ER
<br />2104 College Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />(Ni INSIDE Cr'T"{9,11, tTS
<br />F YES p460
<br />100. ;MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed 111 Divorced 0 Unknown
<br />FATHERS NAME trust,
<br />Lester F Dowty
<br />Middle, L
<br />Suffix)
<br />fOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wi
<br />give maiden name
<br />I12. MOTHER'S -NAME (First, Middle, Malden Surname
<br />Kathryn LaJean Daniels
<br />13 ,:EVER IN U 5 ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Teresa Nelson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />Bztrlal [„Rotation
<br />Crematlori ❑Entombment
<br />Removal> ❑ Ofner(Specffy)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.„FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />in l Faitlft Funera.:Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />16b. LICENSE NO.
<br />1454
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />16c. DATE,:(Mo., Day,, Yr )
<br />March,
<br />1.1b.ZIp Ct
<br />68801
<br />111. PART 1. 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 lines if necessary.
<br />IMMEDIATE CAUSE:
<br />1MMEDIATECAUSE final a)Unknown Natural Causes
<br />didsase or wow-muttbrig
<br />in:dsaR
<br />Sequentially list condidons,11
<br />any, boding to the cause listet
<br />01*line a
<br />Enter 1110 UNDERLYING CAUSE
<br />maxima,iri)UOtaitiiiiiiiiteo
<br />theevents resultingin death).
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Cardiomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Coronary Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Diabetes - Type II
<br />APPROXIMATE INTERVAL
<br />t.to t
<br />Immediate
<br />1L PART It OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting! (3t the underlying cause given in PART I.
<br />Hypertension, Unidentified Neurological Issue, High Cholesterol, Sleep Apnea
<br />40. IF. FEMALE::;
<br />Naf pregnatn within pastysar.
<br />PregMrtt af:tUM of deatiii
<br />Q1:! ket ereg11aeR, b:pre
<br />utgnant within 42 days of death
<br />0 Not pregnant, but pregnant43 days tai year before death
<br />. Unknown N pregnant within the pastyear
<br />22a:`DATE OflNJl3
<br />...............................
<br />22d. INJURY AT WORK?
<br />❑YES 1:3 NO
<br />22f;iLO1rATION:OF INJt
<br />Day, Yr.)
<br />21a. MANNER.OF DEATH
<br />® Natural El Homicide I'
<br />0 Accident 0 pending tmzeetigation
<br />0 Suicide ❑ Gould not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE 0
<br />SCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />knowledge, deathoccurred at the time, date and place
<br />s) stated. (Signature: and Title)
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES] NO [] PROBABLY txj UNKNOWN
<br />2T;NAME TITLE AND AKDDRESS OF CERTIFIER (Type or Print
<br />tate Coli#ns, Hail Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />2113. IF TRANSPORTATION INJURY
<br />0 Culver/Operator
<br />0 Passenger
<br />-:;❑ Pedestrian
<br />0 Other (Specify)
<br />18. WAS MEDICAL EXAMINER :....
<br />OR CORONER Coretet TED?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 64 NO.
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE)
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ..
<br />JURY.At home, farm,. street, factory, office building, constructioi
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 18, 2021
<br />IP CODE '
<br />24b. TIME OF DEATH
<br />Approx. 05:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 17, 2021
<br />24e. On the basis of examination and/or investigation, in my opinion death eCrant(6
<br />the time, date and place and due to the camels) stated. (Signature aid Tkle).
<br />Kate Collins, Hall Deputy County Attorney
<br />24d. TIME PRONOUNCED DEAD
<br />08,1 O AM
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 511 NO
<br />26b. WAS CONSENT GRANTED?::
<br />Not Applicable if 26a is NO YES 044006
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 24, 2021
<br />
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