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<br />4404040,,""'rer. MOWS
<br />STATE_OF....NE.B RASKA
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<br />HEN THIS OPYCARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA rRSJE COPV OP THE ORIGINAL RECORD ON F/Lg. WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATOFSSf ANCE
<br />8/12/2024
<br />LINCOLN, NEBRASKA
<br />202404380
<br />SARAH BOIEINENXA
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />ED lrs+l sstt«:;tFirat, Middle, Last, Suffix)
<br />NY 211 Bt rsan
<br />CERTIFICATE OF DEATH
<br />OnTYANDSTATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />T... ;SOCIAL .SEGURITrt. NU MB ER
<br />8a: AGE - Lasi Blrthtiay ib."UNDER 1 YEAR
<br />(Yrs.)
<br />sb:-EACILLTY NAME`(11 not Institution, give street and number)
<br />$:2 S.:Sbadv:>Bend Road.
<br />8R C1fl OR tOWN iF EA
<br />Grand Island„ 68801
<br />9a. RESIDENCE+
<br />Nebraska
<br />TATE
<br />Include Zip Code)
<br />94 "STREET AND NU EER
<br />;672 S S F ady, Bend. RDad
<br />9b. COUNTY
<br />Hall
<br />78
<br />MOS.
<br />DAYS
<br />O. PLACE OF DEATH
<br />HOSPITAL. 0 inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />Thai MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, butseparatad ❑Widowed 0 Divorced 0 Unknown
<br />11FATHERS:NAME (F)rst, Middle, Last, Suffix)
<br />Ertt2 E D1►sen
<br />t3 :EvER IN U.S A.MED FORCES? Give dates of service if Yes.
<br />(role, No, or Link.) Yes. 12/30/1963-06/22/1967
<br />IL..METHOG,.QF GISPQSmoti
<br />} Bwlat O Doi(stion
<br />j cremation 0 Eilttrmbment
<br />I emove j'dour (Specify)
<br />1Ya: Fl
<br />9c. CITY OR TOWN
<br />Grand Island
<br />10752
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF, )3:RA • t!
<br />u11d
<br />FORO:04t
<br />E. DATE OF 18*RTH (M
<br />JO/ 20F.194&
<br />OTHER 0 Nursing Hom ILTC
<br />® Decedent's Norm.
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE`(FIrst, Middle, Last, Suffix) If wife, give*
<br />Karen Teicka
<br />12. MOTHER'S -NAME (First,
<br />{l Pearl Castor
<br />14a.INFORMANT-NAME
<br />Karen Boersen
<br />185. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />SLYOE Cry! :140111.,
<br />Es <NQ
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />:NAME AND MAILING ADDRESS (Street, City or Town, Stine)
<br />ti FurteralHome, 2929 S. Locust Street, Grand Island. Nebraska
<br />CAUSE OF DEATH (See`fnstruCtl+bns and examples)
<br />14b. RELATlt11
<br />u
<br />iec DATE(Mo
<br />AUQuSt:<1•::
<br />14PART L EntartMblaM of evente..tliteases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such u cardiac arrest,
<br />rasairstary arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Arrest
<br />• or
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />IN Lung Cancer as result of exposure to Agent Orange
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />esti i a eE 0) Diabetes as a result of exposure to Agent Orange
<br />H'Itdtiated
<br />the events result
<br />th)
<br />••PART fi
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d).
<br />1. 49.
<br />W#461401:1.: EXAMl
<br />Pa COR NBER<SOW':121.YES 014
<br />•
<br />IAC
<br />21c. WAS AMA PBY li M
<br />p. vee N(1
<br />THER S1ON)FICANT CONDITIONS -Conditions contributing to the death but not resulting•in ti s underlying cause given In PART
<br />ALE:
<br />Drs(rnaht Whitt.
<br />0 Not pregmYM, htlt ptspntmt within 42 days of death
<br />0. Not pregnant; but pregnant 42.days tot year before death
<br />O unlrOoata;itprailteptwlaik11M 1i year
<br />40#' .334# 0JNJURY (filo:, Dry; Yr.)
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />© Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WER@:AUTOPSN"P`INDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEAT1f?
<br />22c. PLACE OF INJURY -At home, farm;' street, factory, office building,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />F INJCIRY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />kiiewledge, death occurred at the time, date and place
<br />)Stated. (Signature and Title)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 9, 2024
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 3. 2024
<br />0
<br />24b. rim OF DEA
<br />Unkn9W(i
<br />11114 PRONCH
<br />08:41
<br />1,:
<br />24e. On the basis of examination and/or Investigation, M MY. {Oe dei!# etveut�etl>
<br />the -time,
<br />data and place and due to the cause(") dated.tamld itik[t'
<br />Matthew C. Boyle, Hall Deputy County.Attorniey .
<br />2$ DID
<br />AB:CONTRIBUTE TO TME DEATH?
<br />" N VES NO PROBABLY ] UNKNOWN
<br />2T filAiilli; Ti I ANIS BLDG Si OF CERTIFIER (Type or Print
<br />A atths v`C (oyte, Halt Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ;®NO
<br />28b. WAS
<br />Not Applicable If
<br />28b. DATE FILED BY
<br />August 9; 2024
<br />Yr.)
<br />
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