|
t?ct3'.:7$likk4
<br />STATEIOF NEBRASKA
<br />:tt
<br />'Il��IIII�jIdIAArxAt mor,rarntpr �4Rtriighrar>.. Sv4,tx rtftax c4!.Pwa tt't(..1,..
<br />mei. THIS COY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7128/2024
<br />LINCOLN, NEBRASKA
<br />202404'73
<br />310-4 8,44-1Uol
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 ;PECE0ENT8-NAME: {first, Middle, Last, Suffix)
<br />GlenGene Kemper
<br />4:0ITY AND'STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />:.Stanton >Nebraska
<br />IrSOCIAL S URITY NUMBER
<br />5055-56.7'357
<br />Sa.AGE • {.astBirthday
<br />(Yrs )
<br />83
<br />8b. FACIUTY-NAME (If not Institution, give street and number)
<br />CHl Health :$t> Francis
<br />its; CITY OR; TOWN OF DEATH (Include Zip Code)
<br />. Grend.11rland. 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />tib;STREET 'ANC :'NUMBER
<br />1323 R(Ibv Avenue
<br />9b. COUNTY
<br />Hall
<br />b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8s. PLACE OF DEATH
<br />HOSPITALIj Inpatient
<br />HOURS
<br />MINS.
<br />::
<br />3. DATE OF DEAR' law.,3741
<br />July 17, 2024
<br />s. DATg OF BATH (Mo."
<br />March 19 1:9441
<br />OTHER 0 Nursing Home/LTC
<br />❑ ER/Outpatient 0 Decedent's Home
<br />❑: DOA 0 Other (Specify)
<br />105 MARITAL BTATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />,:FATHER&NAME (First, Middle, Last, Suffix)
<br />Bernhard T )eloper
<br />13r6ER IF1 U8 ARMED FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk.) No
<br />IL METH04:,QF pisepsITION
<br />;® Buda(,':;Donation
<br />CremaEttn❑ Entombment
<br />❑
<br />❑ Removal Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE(First, Middle, Last, Suffix) If wife, givens&
<br />JoAnn R Arnold
<br />I12 MOTHER'S -NAME (First, Middle,
<br />Christine' Stauffer
<br />14a. INFORMANT -NAME
<br />JoAnn R Kemper
<br />18a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18b. LICENSE NO.
<br />1537
<br />18d. CEMETERY, CREMATORY OROTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17d :FUNERAIL HOMC::NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Apfel Fu:reral Houle, 1123 W. 2nd, Grand Island, Nebraska
<br />Maiden Sur
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1a.. PART I. 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 venbicular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />14 Metastatic disease involving the braid'
<br />MiMEDIATE OUSE (Final
<br />disease or uuudaiotl yaultlay
<br />taX1 5th) .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions,if b)Metastatic Papillary Thyroid Cancer
<br />sn1r Ieading:tq:the caugrlisted
<br />online a.
<br />Eeriat.the Uk ftLVING CAUSE
<br />...: ...
<br />(Millie or lite* thlitt.firitised
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP TO .ECE
<br />Spouse
<br />$C- DATE 4
<br />JUN 2t1 24)
<br />18; PART N OTKE S1GNIFICANT CONDITIONS -Conditions contributing to the death but:not resuidn. p In the underlying cause given In PART I.
<br />Vitamin D 6eficiency, Ulcerative colitis, Asthma, Transitional Cell Carcinoma or(he bladder, Hypertension, History
<br />Melanoma, Metastatic bone disease, History of Adenocarcinoma of the left lung
<br />20: FEMA).E
<br />. rll7t pregnene within past year
<br />Pregn*d at rhos et dipitir
<br />❑ Notpre n set but pregnatrt within 12 days of death
<br />0 Not puptsm, but pregnant 43 days to 1 year before death
<br />.❑ Ur,kaoaat #Dra9aatR.t, lthi the Wet year
<br />2. DATE OFINJURY tt?o., Day Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />ml YES:::❑:NO:::..
<br />22c PLACE OF:INJURY-Mho
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OFMNJORY STREET b NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 17, 2024
<br />23b.DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Jyily 45 :2024 08:59 PM
<br />34; TAare b¢atofthy knowledge, death occurred at the time, date and place
<br />sptl don [e tha cause(s) sated. (Signature and Tithi)
<br />Kimbedv A. Mickels, MD
<br />000::USE:.:CONTRIBUTE TO THE DEATH?
<br />l NO l PROBABLY 0 UNKNOWN
<br />21b. IF TRANSPORTATION INJURY
<br />D Onver/Operator
<br />© Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />,
<br />0048
<br />4*
<br />r.
<br />1s.WAS M$EK',AL'i7(A(i__NB R.: !.
<br />OR CUROhtiii! GONTALTET>7
<br />Ye, 60' NO'
<br />21c. WAS AN AVTOFSYMS110i
<br />❑ YEs..
<br />21d. WERE AUTOPSY:10 NGi3 A 'Au.AHi,.t
<br />TO COMPLETE CAUSE O1: USA'
<br />❑ YES.:::
<br />ferm street, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b: Tlt®E'OF
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIMEPOONOUN
<br />246 Onthebasis of examination and/or investigation,in mu
<br />:tlietime, date and place and due to the cause(s) ttaMl. (
<br />28a. HAR43RG444:0R,TISSVE r ® ATK)N:.B.EEN CONSIDERED?
<br />❑ YES -0i
<br />2T: NAM tine ANTS ADbRESS OF CERTIFIER (Type or Print
<br />ifittibetlA TVllckels, MD, 729 North Custer Avenue, Grand'tslandNebraSkia, 68803
<br />20e. REGISTRAR'S SIGNATURE
<br />at -4,0-7
<br />26b. WA$
<br />Not Applicable if
<br />28b. DATE FILED 0i
<br />July 25, 2024'
<br />
|