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<br />I 1 fEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,,. IT CERTIFIES THE DOCUMENT BELOW
<br />BE=TRUE PYoFTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA .;:DEPARTMENT OF HEALTH AND
<br />UINAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />WOOF OF St tCE
<br />/312024
<br />LINCOLN,'NEBRASKA
<br />pECEp N)"S44AME? #Ptrst, MI
<br />Dean' '.'14110;Hatms
<br />e
<br />202405047 304,01
<br />SARAH BOHNEN
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />:'Ct'IY'AND:STA-M OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />x;;0oCIAL `sEC uRD I`NUMBER'
<br />ab: FACWTY.NAME (It not instlt
<br />CHI: Health .St;.; Francis
<br />5 Ct7Y OR WN'OF AEA'
<br />C;r&rad<tllefld 88803
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />1d: STREETANt)NlfitpE R
<br />A2 S[u:r Lane:;€<
<br />to give street and number)
<br />ude Zip Code)
<br />9b. COUNTY
<br />Hall
<br />1tla '#A'ARITAit $TA itj3 AT I1ME OF DEATH ® Married 0 Never Married
<br />El Married, but sepatted ❑Widowed ❑Divorced 0 Unknown
<br />1
<br />aim
<br />OE:#first, Middle, Last, Suffix)
<br />S
<br />Give dates of service If Yes.
<br />fYOsc No, Of UPk)1VO
<br />EPOBrfION
<br />Daiaffon
<br />Ehoirtbtnent
<br />Othei (SPecIfy)
<br />5a. AGE - List Birthday
<br />(Yrs.)
<br />74.
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Se. PLACE OF DEATH
<br />HOSPITAL E Inpatient
<br />0 ER/Outpatient
<br />[} DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DAYS of;c
<br />Juns 25:
<br />S. DATE. OF MIRTH
<br />August
<br />OTHER 0 Nursing Home/L
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Sd. 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, give maiden
<br />Eileen DeVries
<br />1:2,<Mott-te -WANE (First, Middle, Mal
<br />Darlene DeNeui
<br />14a. INFORMANT -NAME
<br />Eileen Harms
<br />16a.EMBALMERSIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b.
<br />SIIousl
<br />Sc.':DAT•
<br />June
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />i
<br />NERA.,HO►NENAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Puneral;l-iame, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (ee instructions and examples)
<br />L t3Ner thsolte1n of sveots, gNaaus, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />it vitrtdoutar 94dilation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if neceesery.
<br />IMMEDIATE CAUSE:
<br />a) Septic shock .
<br />Sequentially i� condtsom
<br />''Ent rtfieU140.. 4Yl lGci
<br />Idiseise or ifijit4theftitit
<br />the events resulting id daai
<br />::APP
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />,a' b)tlrinary Tract Infection
<br />AItT II O 'IdER:Rliat
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E c) Bladder cancer
<br />DUETO, OR AS A CONSEQUENCE OF:
<br />ADA
<br />SNT CONDITIONS -Conditions contributing to the death butnot resulting' In the underlying cause given` in PART I.
<br />In 42 days of death
<br />dye td 1 year before death
<br />pest year
<br />DA fR OF INJ )R :#into., Driy, Yr.)
<br />21a. MANNER OF DEATH
<br />Ea Natural HomIcide
<br />❑ Accident 0.Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b�-.IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />CIPassenger
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />21c. WAS
<br />❑ YES°
<br />21d. WEREAUTOP1l
<br />TO CONPL[TE GALAS
<br />❑ TES:
<br />22c.'PLACE OF INJURY -At dome, farm; street, factory, office building, do
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />o., Day, Yr.)
<br />25, 2024
<br />, Day, Yr.)
<br />24
<br />23c. TIME OF DEATH
<br />04:03 PM
<br />knowledge, death occurred at the time, date and place • .
<br />ie(e) haled. (Signature and Title)
<br />has, PA
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c.PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24i: Onihe heels of examination and/or investigation, tit n
<br />the time, date and place and due to the Cause(s) suit&'
<br />26a. HAS ORGAN OR TISSUE DONATION: SEEN CONSIDERED?
<br />❑ YES. ®NO
<br />fR(BUTE TO THE DEATH?
<br />::0; PROBABLY 0 UNKNOWN
<br />AN iADDRESS OF CERTIFIER (Type or Print
<br />Xaagat)as, PA, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />26b. WAS CO
<br />Not Applicable if 2
<br />28b. DATE FILED'ISY R
<br />July 1, g024,,.:
<br />
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