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' " • ' - • ,41%,471100 . - -
<br />STATE OF NEBRASKA
<br />.; • •I1, - . •
<br />6V49 404046
<br />KEN is 60* Oft04 74 louse° SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT Boxow TO
<br />V:::mE.c.op7 ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />AN'seRvicts, virAL wiateos OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />4 gd4eil4et
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTTUAIR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />, .
<br />• • riiitE:30400(144i400v:'
<br />giti7./2025
<br />.LimpoLti,..imgraRASKA.:
<br />k.„
<br />202500497
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFpkTE OF DgAill
<br />g MANI Last, Suffix)
<br />-
<br />Simonds
<br />,4.CliYAND$ThTE ORTOTNTORY, OR FOREIGN COUNTRY OF BIRTH
<br />•
<br />11041184
<br />DIAL,8gCORITY''NIOM4E# •
<br />A01 41.04.40011.
<br />Alaie;PiAte. Cent
<br />C;CITY'.011 lIblaif.0,:tiaart(1ndNO•ZI Code)
<br />• Witt:46g*
<br />art t4abat.,
<br />•
<br />e
<br />reet and number)
<br />9b. COUNTY
<br />Hall
<br />Weritaidlivkl
<br />OF EATH 6D Married Never Married
<br />,
<br />led,. but ' Divorced 0 Unknown
<br />• •
<br />11.4ATHER!844A8il5 fr*t Mlddl. Last, Suffix)
<br />Ralph
<br />8,EVER
<br />ri • No
<br />'
<br />•••••i4tiofl Dn*onbm,fl
<br />" ' **it'll
<br />es of serveif Yes.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />5b, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />a. PLCEOFOEATh
<br />HOSPITAL 0 IngatIont
<br />0 ER/Outpatient
<br />HOURS-
<br />MINS.
<br />3. DA
<br />a
<br />S. DATE OP,
<br />July 12,
<br />OTHER El Nursing Hams/LTC
<br />0 Decedent's Home
<br />0 DOA El Other (Specify).
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />tic APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give le
<br />Juanita Betlach
<br />14a. INFORMANT -NAME
<br />Juanita Simonds
<br />16d.PEMETERY, CREMATORY OR OTHER LOCATI
<br />Central Nebraska Cremation Services
<br />IOMNAME:ANO MAILING ADDRESS (Street, City or Town, Statiek
<br />Farattal HOW 2929 S. Locust Street, Grand Island, Nebraska
<br />12. MOTHER'S -NAME (First, Middle, Maiden
<br />Maxine Cory
<br />les, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rut showing the etiology. DO NOT ABBREVIATE. Enter only one ceuse on line. Add additional lines if necessary.
<br />LAB-TQ,OR AS A CONSEQUENCE OF:
<br />,0068110B4Ii°4.."! 0)-tarigestive heart failure
<br />.1ta A CONSEQUENCE OF:
<br />.4,44144:0000INBOAA/$8,"
<br />':SINui*,4r,inivry_stifklittorod "
<br />OR AS A CONSEQUENCE OF:
<br />:15. Rfl-QTHERSIqNliANiC�$DITiONS.CondItions contributing to the death but not resulting In
<br />VeMebrailiasiliOnsOficiartsy;' mil , cognitive impairment, chronic obstructive pulmonary disease
<br />; L.
<br />MitS
<br />tosko.scka
<br />.„,ntednilinit,Iii4 pregnant's/10111142 day*Of death \
<br />, „.•
<br />oar% lArAtiforiitant lta 441 Ito Otor before death
<br />.010AAAVOraraiiiitot*Aiii'the beet, year
<br />PANJLARY
<br />AT
<br />Yitt
<br />21a. MANNER OF DEATH
<br />R1 Natural 0 Homicide
<br />Accident 0 Pending Investigation
<br />ElSuicide Could not be determined
<br />22b. TIME OF INJURY
<br />eunderlying cause given in PART II.
<br />21b. tr TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />El Pseitentler
<br />El Pedestrian
<br />EI Other (Specify)
<br />21c. WAS A A
<br />0 YES
<br />21d. WERE AUTO,•flf4flt
<br />TO COMPLETE CAM
<br />. .
<br />YES „
<br />22c. PLACE Off INJ °me, a street, factory, office building, conat
<br />BE HOW INJURY OCCURRED
<br />TI NUMBER, APT.NO.
<br />LtMO, Day, Yr.)
<br />-
<br />b. pATe'SieeteitMe..;>eily,'Yr.) 23c. TIME OF DEATH
<br />•
<br />4 ry:402(15, 03:20 PM
<br />:Ibitte.tairOf thilindadedge death occurred at the time, date and place
<br />the:OtieetsEsteten, (Signature end TRW
<br />•
<br />CITY/TOWN STATE
<br />2
<br />5
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24 , PRONOUNCED DEAD (Mo., A'..0ay, Yr.
<br />24b. Tt
<br />244. On the Stift of eseminetion and/or inveetigation, in ray 000109
<br />the tette, date and place and due to the cause(sisteted. Mane .
<br />. „....,..,,CO!EORTSUTETO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION 6EEN CONSIDERED?
<br />Ngl':::!:fl::,BROBAtEILY 0 UNKNOWN 0 YES fil NO
<br />.; /AMC..tiiikatia*aaatit OteNTIFIER (Type or Print
<br />'t 1.' Brown...MO,' 29 North Custer Avenue, Grand Island, Nebraska, 68803
<br />T
<br />NAT
<br />28b. WAS NS
<br />Not Applicabl
<br />28b. DATE FILE
<br />..... • ''
<br />
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