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<br />STATE OF NEBRASKA
<br />N'tttttl;CCffOfft r. ar2mainso. ::;!. d44liyr l'.f9DJm.
<br />WHEN THIIS:cpPY' CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERi7I IES THE DOCUMENT BELOW TO
<br />BE A TRUE:COPY :OFTHE ORIGINAL RECORD ON FILE.WITH'THE MEI91?ASKA DEPARTMENT OF HEALTH AND
<br />'HUMAN SERVICES, WTAL RECORDS OFFICE, WHICH IS THE'LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2/14/2024
<br />LINCOLN, NEBRASKA
<br />20240627
<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 />1- DIaCEIaENTS-NAME:::(First, Middle, Last, Suffix)
<br />:Aicha;rd <:AIAri . Necker
<br />CERTIFICATE OF DEATH
<br />{ cITtiAND;STATE OR.TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7 :rL3'GiltL SEOuRI'ee NUMBER
<br />505-78-9.328.
<br />dt FACILITY NAMEfff<not Institution, give street and number)
<br />CHI Health St, Francis HMS
<br />Scs;CI1`Y:OR7'OWN':OF:DEATH (Include Zip Code)
<br />Graltd I nd::68803
<br />9a; RESIDENCE -STATE
<br />Nebraska
<br />eat. s.rea.ET:AHO NUMBER
<br />9b. COUNTY
<br />Hall
<br />Si: AGE-"LastSirttu(ay.
<br />(Yrs.)
<br />70..
<br />1Da..:MARITA4'STATUS.ATTIME OF DEATH f Married 0 Never Married
<br />0 Married, bud separated ❑ Widowed 0 Divorced 0 Unknown
<br />11„E ATHER'$44AME. (First, Middle, Last, Suffix)
<br />-OYaI' V' 'Neckerc'>
<br />12 :;r ilER.'IN 1) S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15, METHOD OF DISPOSITION
<br />: aiiriu1 :<'.< Dniiietlon
<br />Cremaition QEntanibment
<br />:flpmov5l [ biti r (Specify)
<br />14a. IN
<br />Craig
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Sb,
<br />DER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a: PLACE OF DEAT1*;
<br />HOWL 1E3 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />2401912
<br />3. DATE OF DEI(STN (Me i acltiy :ti"[,)
<br />February 024<
<br />S. DATE OF BMTN'(Mo.,'
<br />November.5,,:1:953.'.::>:::
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Hospice F3 cility
<br />39g. INSiDIw;'Ci
<br />YE$":
<br />IOb. NAME OF SPOU) Middle, Last, Suffix) if wife, give maiden n
<br />Gwendolyn ©•
<br />FORMANT-NA
<br />Necker
<br />12.MOTHER'.S-NAME (First, Middle, Maiden Surname);
<br />RDJrsn:: A Nelson
<br />E
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL,HOME, NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />;;Curran Ftineral`Chapel, 3005 S. Locust St., Grand Island2'Nebraska'
<br />15b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH ISee.instructiOtig..artd examples)
<br />12. PART I. Enter the chain. of *vents- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />ItaittoiEcalla real "' ;; a)Acute Hypoxic Respiratory Failure.:::
<br />4115001111 .tondit{un:resuliktil.
<br />sequentially bet conditions, If
<br />any, leading to the muss bated
<br />s
<br />Emir the1JNO£tRLYING:CAuSE
<br />tdkn it :.oi INw tit t adt ted
<br />the *vents resulting In death)
<br />LABT
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Lung Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Pulmonary Emphysema
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />OTHER; SIGN) ICANT C
<br />Trans ttOned to dprrtfort cares
<br />^20,.IF,FEMALE:
<br />Ndt:prWrt+ t /00:tiai;l:ygr
<br />p pt4. 4 *;fin» k•4
<br />Not ok,2sdt; but'pf:Tgriant within 42 days of death
<br />Lj Not poignant, but pregnant 43 days to 1 year before death
<br />0.,:„Boknowhi1Sregossf within the past year
<br />DITIONS-Conditions contributing to the death bt not
<br />22as:PATE
<br />OP INJURY
<br />22d. INJURY AT WORtK?
<br />OYES ❑NO
<br />Day, Yr.)
<br />Wang In the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hoinfude
<br />❑ Accident 0 Pending Investiqution
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />;1b. IF TRANSPORTATION INJURY
<br />orNeriOpsrator
<br />::. Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />e:
<br />144, RELATIONSNiP TD0CEDli*NT:::
<br />Son
<br />lac. DATE
<br />Februe
<br />OAy, Yr.) ...;;::.
<br />APPROXIMATE INTERVAL
<br />it WAS MEbTCAt, EX tMtt.tR
<br />OR CORONR�'CtOHTA?
<br />0 YES .,46c NO
<br />21c. WAS AN AUTOPSY'tt]
<br />YES
<br />0
<br />21d. WERE AUTOPSYFINDINGS'AVAILABLE
<br />TO COMPLETECAUSE OF DEATH?
<br />❑ YES ❑.:NCI.::...
<br />22c. PLACE .OF,INJUI Y At loin, farms street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />A`T oe OF INJURY:' STREET d NUMBER, APT.NO.
<br />23s #,1ATE'OPDEATHF(Mo., Day, Yr.)
<br />February 7, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Febrant;:8, 2024
<br />CI
<br />23c. TIME OF DEATH
<br />02:05 PM
<br />33a.;To the b tat of 00kn w ledge, death occurred at the time, date and place •.
<br />• :: ands do.'to tirecause(s) stated. (signature and Tide)
<br />MidiaelA'Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />�YE$ ...©NO..:.::.❑PROBABLY 0 UNKNOWN
<br />27..N ME, TITLE.AND DDRESS
<br />OF CERTIFIER (Type or Print
<br />Ttf.iChael:A Donner, MD, 7 9 North Custer Avenue, Grand
<br />25a. HAS ORGAN OR TISSUE r
<br />0 YES::'::; RI NO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />04S4> pagi
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />Ste..On *abash' basis of examination and/or investigation, in my opts len d1 R1l ,i.... gtr54 t
<br />the 11Me, data and place and due to the muse(*) stated. lslgnatum:hidi11itts) ..::
<br />TION BEEN CONSIDERED?
<br />and,and, Nebraska, 68803`
<br />28a. REGISTRAR'S SIGNATURE
<br />25b. WAS CONSENT GRANTED?.:
<br />Not Applicable If 259 is NO OYES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 13, 2024
<br />
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