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STATE OF NEBRASKA
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<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME
<br />pia hails of examination end/orinvestigatlen, le my op
<br />tins, date and puce and due to the camels) stated. (elgnaaWra
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 10No
<br />• tFAk1E,'%1TU AND ADDRESS a CERTIFIER (Type or Print
<br />Steven Huseri; MD, 211E W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />1'S SIGNATURE
<br />i!Yl{EN t COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE TRUE COPY OP 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 />ATE OF:!SStIANCE
<br />.:1I1 2023'
<br />RA
<br />: DDENT`SlNAN1>~"iFIns,
<br />Douglas L: 5 , •Ood
<br />202405341
<br />30-4
<br />RAH 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 />Iddls, Last, Suffix)
<br />t CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, :Nebraska:.
<br />7 5OCIAL SECIJRi
<br />62.1262
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />TY O TQlsflil OF DEATH (Inc(uds Zip Code)
<br />Adalrret'. 68883 ..
<br />ea: RE$b
<br />Nebr
<br />NCE-STATE
<br />$tl.15111ffiET:AN( ;NUMEiER,
<br />1335<'Li ly Street:;' .:
<br />9b. COUNTY
<br />Hall
<br />lfia MA}f TALSTXiDEATH ® Married 0 Never Married
<br />0 Married, but separated J Widowed ❑ Divorced 0 Unknown
<br />j1. FATh Rl .NAlbE"(First; Middle, Last, Suffix)
<br />CharlesRobert::.:Codner.
<br />:A , steOFORCEs? Give dates of service if Yes.
<br />nk.) Yes 05/22I1968-02/24/1970
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />74.:::::
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />tie:: PLACE OIt.175EATH
<br />HOSPITAL_'❑ Inpatient
<br />0 ER/Outpatient
<br />(p oQA :..
<br />9c. CITY OR TOWN
<br />Wood,:River
<br />HOURS
<br />MINS.
<br />3. DATE OF ctio:o#I,(Rd:,
<br />Jant4aty,3�`2 a ..
<br />6, DATE OF BIRTH MAo., flay. Yr.)
<br />Septa
<br />OTHER 0 Nursing Horne/LTC'
<br />® Decedent's Hems
<br />0 Othe►(Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Bs. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give mal
<br />Karen June Allan . ..
<br />I.'..12. MOTHER'S -NAME (First, Middle, Maiden Sum
<br />Luetta : Mae Dubbs
<br />14a. INFORMANT -NAME
<br />Karen June Codner
<br />lea. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16), LICENSE NO.
<br />1.191
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />.FUNERAL t(QME.$ ME AND MAILING ADDRESS (Street, City or Town;:State).
<br />A :t4). n r l Home ;1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See'instructions slut examples)
<br />A
<br />ails, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such** cardiac arrest,
<br />venirfuuiar fiixitietiorrwidrout *hewing thertiology.00 NOT AfBRE:,ATE. Enter only one cause on a Ih». Add additional ureic 8 peninary.
<br />IMMEDIATE CAUSE:
<br />End stage congestive heart failure, chronic: combined sytolic diastolic congestive heart
<br />failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />itlimy , b)Arteriosclerotic cardiovascular disease
<br />stu?t[Ytad
<br />TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />OIttt
<br />jtc PlrR'r. o rogfi St.FtCANT CONDITIONS -Conditions contributing to the death but notri►suItirig in thi underlying cause given in PART I.
<br />Type 4 :diaIsetee, atonic kidney disease stage IV, hypertension, cerebrovascular disease
<br />nou
<br />:.::(Ma.,.Day,
<br />22d. tNJURY AT WORK?
<br />:DYES
<br />22e,
<br />21a. MANNER OF DEATH
<br />® Natural D fiemicidu .;.
<br />❑ Accident ❑ Pending lnvaatlgatian
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.::IF TRANSPORTATION INJURY
<br />DAvaHOperator
<br />Peenger
<br />• 0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN A
<br />0 YES
<br />21 d. WERE AUTOPSY
<br />TO COMPLETE CAUSE
<br />❑ YES
<br />22c. PLACE OF INJURY.* home, fang strsst, factory, office building, construction
<br />IBE HOW INJURY OCCURRED
<br />2f lOCATION MP itAt ttt.Y', :STREET & NUMBER, APT.N. )
<br />CITY/TOWN
<br />UAL .DA'!M OF DEATH (Mo., Day, Yr.)
<br />January 3, 2023'
<br />23b. DATE SIGNED (Mo 'Day, Yr.) 23c. TIME OF DEATH
<br />,)& itlllj^ti+>' . 2023 10:25 AM
<br />2 It Te NF beat oi'tiiY knewledaa, death occurred at the time, data end place
<br />..... ..... yltte"fh tiottiuiets) staled. {Signature and mist
<br />en Husen, MO
<br />BACCONTRIBUTE TO THE DEATH?
<br />0 pROBABLY ❑ UNKNOWN
<br />26b. WAS COHSE
<br />Not Applicable If 28a la NO
<br />28b. DATE FILED BY REGI
<br />January 4, 2023
<br />y,:Yr.)
<br />
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