|
�t1�'I'e�.riSMJaSwx,';;`-xsYt40 Aare.,�•:<zsa6htWigN®ava`d•.:•eaa p1.as:;....,�2RAh.t4Mt�:/•i'i'i4��'���yl�l/i1A,111t1�i�.�\e'��',.
<br />..:..- :,:.ate.-..-.�rt�sv.,�-'.....a.,�-...�..�:�>?ztQQ4i.BSY'1�•.s..<...-. ....,..:......-.-..--
<br />STATE OF NEBRASKA
<br />IEN r COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A TRUE "COPY 'Q'THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAN SERVICES,VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202405724
<br />�1etP 01,tet Ike
<br />SARAH BOHNENKAMP f
<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 />iridle Last, Suffix)
<br />RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />(It not lnsdtutlon„give street and number)
<br />Getitr l:Ne ra k8<Veterans Home
<br />C )MI 11` OR TO N O DEATH (Include Zip Code)
<br />Ke neY 68847">
<br />9b. COUNTY
<br />Hall
<br />fREETAND NUMBER;
<br />Ct4 Mea IOW:ROad
<br />jA19►TAL STATUS AT TIME QF DEATH ® Married ❑ Never Married
<br />Nitlitried.:bkifseparated { Widowed ❑ Divorced ❑ Unknown
<br />ATHEtI`$=N7k14 F.:.(First' M(diib
<br />ut7fi :€McVay E pf Sr -
<br />rR IN U'S.. ARME
<br />, NO, orUnk3Yi
<br />Last, Suffix)
<br />? Gi a dates of service If Yes.
<br />711968-06/25/1974
<br />2. SEX
<br />Male
<br />5c. UNDER 1.DAY
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />80,:.PLACE QFDEATH .
<br />HOSPITAL [] inpatient
<br />❑ ER/Outpatient
<br />© DOA •
<br />9c. CITY OR TOWN
<br />Grand Island
<br />ile. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />.DA
<br />Ot
<br />b..
<br />4
<br />Yr:3
<br />AF`S(RTF((Mo Day, Yr.)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give t1t+idilh n
<br />Patricia Springer .. .
<br />14a. INFORMANT -NAME
<br />Patricia Miner
<br />ea. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />10d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Bass Point Cemetery
<br />It itNtd #At ".FI CA ;NitME:AND MAILING ADDRESS (Street, City or Town; State)
<br />II aiths f rli ra;: ii€ a 2929 S. Locust Street, Grand Island, Nebraska
<br />ni is►;of t widN ui re
<br />qes#+) DUE i`O, OR AS A CONSEQUENCE OF: ores&
<br />dwnaany::ita im/081001.4:; b)
<br />DOE TO, C?R AS A CONSEQUENCE OF: ;rile
<br />2. MOTHER'S -NAME (First, Middle, Maiden
<br />Catharine Buettner
<br />Sb. LICENSE NO.
<br />CITY / TOWN
<br />Boone
<br />CAUSE OF DEATH (See instructions and examples)
<br />eases. Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />tedon wkhout showing the etiology. DO NOT ABBREVIATE. Enter only ono cause Ana line. Add additional lines if necessary.
<br />(O(ATE CAUSE:
<br />a)tewy body dementia
<br />et ttN uNDBRL't9NC# tt'Atiae 0)
<br />Or slurry alrf MtikHilsd
<br />}
<br />TO.OR AS A CONSEQUENCE OF: : an
<br />d), .
<br />PA1YT`. Of#iER SIi2HI CANT Col1DmONB-Conditions contributing to the death but not resulgeig in: the underlying cause given in PART t.
<br />jyiant' t thin Rest r .
<br />i1i a4 iiitie bt iiOir .•
<br />grant, itbtpngnentwithin 4,4 days of death
<br />gmtF, .:.htyt.QlPgnenf 4 fl(sys to 7 yesr before death
<br />21a. MANNER OF DEATH • . . .:
<br />Natural 0 Hi ni Ida :
<br />0 Accident 0 Pending Investigation
<br />El Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21D.: if TRANSPORTATION INJURY
<br />Q Dr+.verlOperator
<br />0 Passenger
<br />El Pedestrian
<br />0 Other (Specify)
<br />21 c. WATT AN AUTOPSY P
<br />D u mi
<br />21d. WERE AUTOPBYl i i((It38 AVA(t
<br />TO COMPF
<br />El YES'
<br />22c. PLACE OF INJURY At hifttte, farm, street, factory, office building, conelnt
<br />(1TIil7'Q INJEI;iY STREET A NUMBER, APT.NO. CITY/TOWN STATE
<br />I CIF DEA (H (Mo., Day, Yr.) = 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME
<br />`b tA.(,?024' S g W
<br />t l lEf,3:(Mo„ Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 2+W-TIME
<br />ii 4 05:35 AM .t
<br />(iii/t pfAt yi"kabWlatlss delith occurred at the time, date and place 32i, On ttie basis of examination and/or Invest(stio d my
<br />g m,i
<br />ly t# t1if ipioF}ii{i allied. tsignature and Title) the time, date and place and due to the causes) stated,
<br />kNester, MD '- S
<br />US ,c. N€BiBt)TE TO THE DEATH? 26a. HAS ORGAN OR TISSUE BONATION'BEEN CONSIDERED? 26b. WAS CONS!t1
<br />`PR09FAEILV 0 UNKNOWN ❑ YES ::NO Not Applicable N.2tia i
<br />NOr AEIp OEERTIFMER (Type or Print
<br />elltge,1 4908 Cass St, Omaha, Nebraska, 68132
<br />2513. DATE FILED BY GI
<br />October 9, 2024','
<br />
|