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STATE OF NEBRASKA
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<br />N;' HISS. COPY G ARRIES THE RAISED SEAL OF STATE OF. NEBRASKKA; IT CERTIFIES THE DOCUMENT BELOW TO
<br />6:A TRUE;,COi Y 0 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 />ATEOFISSUA
<br />1 /20/2022 "'.
<br />L INCOLN, NEBRASKA
<br />g EDENT'S.NAME.(Ftyst, 1
<br />Mane " Ellen *moron
<br />4. City:ANS STATE QR; TER
<br />e Last, Suffix)
<br />Y,ORF
<br />SARAH ROHNENTCA.,.. r
<br />202406071 ASSISTANT DEPARTMENT F HEALTH
<br />REGISTRARE
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />IGN COUNTRY OF BIRTH
<br />Loup City. Nebraska
<br />SOCIAL SECURI'(Y NUMBER
<br />`505-5842236
<br />w F OIUTY NAME(If not Institution, give street Ind number)
<br />CHI<Health,St :.Francis'
<br />CITY ORTOWN ?F rATH (Include Zip Code)
<br />rand, Island =68803
<br />�a RESIDENCE -STATE`
<br />.Nebraska
<br />.STiEETANDNUMBioR..;; ' ..
<br />7`;Ar'izorna Ati unte.':...,
<br />9b. COUNTY
<br />Hall
<br />OA MARITAL :E ATO AT,Timg OF DEATH ® Married 0 Never Married
<br />Minted,,btrt Np•ratirl 0 Widowed Q Divorced 0 Unknown
<br />FATHEk S-NAME (Firi t,:' `Mi
<br />Sri .:>> Glinsmaflrl:
<br />Ne
<br />All Faiths
<br />Last, Suffix)
<br />service if Yes.
<br />BALLMER-SIGNATURE
<br />ie M, Smydra
<br />Sis AGE - Last: Birthday
<br />(Yrs.)
<br />76
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8a.' PLACE OF DEATH..'
<br />HOSPITAL S] Inpatient OTHER 0 Nursing
<br />❑ ER/Outpatient 0 Decedent's Horns
<br />❑ DOA 0 Other (Specify)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />3. DATE
<br />NOVI
<br />6, DATE
<br />9e. CITY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First,
<br />Edward Hoegren
<br />9e. APT. NO.
<br />Middle, Last,
<br />M. ZIP CODE
<br />68603
<br />Suffix) If wife, give
<br />12, MOTHER'S NAME (First, Middle,
<br />Florence Irene Dethlefs
<br />14a. INFORMANT:NAME
<br />Edward Hoegren
<br />111d. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Westlawn Cemetery
<br />g ANtt MAWNQ ADDRESS (Street, City or Town; State)
<br />1<' ome,2929 S. Locust Street, Grand Island, Neb
<br />16b. LICENSE NO.
<br />CITY ! TOWN
<br />Grand Island
<br />CAUSE OF DEATH: (See instructions .Sold examples)
<br />injuries, or compiicetionadhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one Um. Add additional lines If necessary,
<br />CAUSE:
<br />ngestive heart failure
<br />, OR AS A CONSEQUENCE OF:
<br />b4Hypertensive and valvular cardiomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E TO, OR AS A CONSEQUENCE OF:
<br />i4R^C;li cri HERt RGt .C/4NrcONDr oNa-Canditions contributing to the death fit not meaning it::l
<br />rr type It; diabetes mellitus, and obesity
<br />vHBtin taut year
<br />Kit pregnant wlthIn.42'days cf death
<br />but pregnant 11s.days to 1 year before death
<br />In *repast year
<br />B
<br />U11rt STR
<br />21a. MANNER OF DEATH
<br />Natural Homicide
<br />0 Accident pending Invhetigatlon
<br />0 Suicide Could not be determined
<br />22b. TIME OF INJURY
<br />underlying cause given In PART L
<br />214, IF TRANSPORTATION INJURY
<br />Q:
<br />DddveUOpantor
<br />Pasasnger
<br />Pidestnan
<br />Other (Specify)
<br />214.,,WAS
<br />YES
<br />21d. WERE
<br />TO C
<br />lin YES
<br />22c. PLACE OF INJURY -At home, form, street, factory, office building, construct!
<br />INJURY OCCURRED
<br />MBER, APT.NO.
<br />ATE Ot DEATH (Ma., Day', Yr.)
<br />lco. embar 5, 2022
<br />G (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />•a4.2022 02:45 AM
<br />cwWda; death occurred at the time, data end place
<br />e) stated (Signature and Title)
<br />D.
<br />TO THE DEATH?
<br />ILY ® UNKNOWN
<br />E, Tl r1 La iANp A RESS OF CERTIFIER (Type or Print
<br />Erin M Liiiritie,: MD •4840.F St, Omaha, Nebraska, 68117
<br />. 2$lr. MenistRtAR'S SIGNA
<br />26a. HAS 0
<br />El YES
<br />GAN OR Ti
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />) fit17264
<br />H M1R, D4i, Y!` ,.
<br />}(iiio, DiY VrY -
<br />tit
<br />AV,
<br />11 ., PRO NOOUNCE,y., .D.. .
<br />24d. TIME DEAD.
<br />244. On the bale of examination and/or Investigation, in ray eplpl n dUUh
<br />Me time, data and place and due to the cause(*) atuted. (Stgnaa fttMm :
<br />UE DONATION BEEN CONSIDERED?
<br />+..JI'i �Ssc.r fit. rn_ s"
<br />26b. WAS CONSENT GRAN 3k1
<br />Not Applicable H 261 Is NO
<br />28b. DATE FILED SY REGISTRAR
<br />December 15, 2022
<br />; Yr.)
<br />
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