|
-xq916916rif
<br />I ? atFaa.R.
<br />itte
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF 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 />f)J;TEs6P.ISSUANC .
<br />11 /15/2024
<br />/LINCOLN, NEBRASKA
<br />202500
<br />19
<br />d. MI? ? :i lk 4 i' l 4 tn,
<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 />CERTIFICATE OF:DEATH
<br />DECEDENTS-NAME:(Fleet;:, Middle, Last, Suffix)
<br />Sandra Lynn Kemper
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island; Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />I507:-56-070A
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tabitha at Prairie Commons
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island' 68803
<br />5a. AGE - Last Birthday-
<br />(Yrs.) \
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa:. PLACE OF DDATH
<br />HOSPITAL ❑ inpatient
<br />0 ER/Outpatient
<br />DOA::
<br />HOURS
<br />MINS.
<br />2415317
<br />3. DATE OF DEATH (MO., Dltp Yr )
<br />November 2, 224
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 12,:194 6:<'
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />'Hall
<br />'::Hospice Foci
<br />ty
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />• Grand l5i8nd
<br />9d. STREETAND:NUMBi R ::
<br />4110 Sun Ridge Lane'
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />11..FA:THER'S-NAME (fusty Middle, Last, Suffix)
<br />Fre.OricX1 Schwieger
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15:.METHOD ;OF DISPOSITION
<br />❑ Burial 0Donation...
<br />vu Cremation ❑ Entombment
<br />0 Removal 0 Other (Specify)
<br />00.. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />INsips CITY LIM)TS
<br />® O ND
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dennis Kemper
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ruth Scherzberq
<br />14a. INFORMANT -NAME 1
<br />Dennis Kemper
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a<FUNERAL HGME NAME:'AND MA LING ADDRESS (Street, City or Town, State)
<br />,iiAlkFaittitS:;FUriierat Home, 2929 S. Locust Street, Grand Island; Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />ta. PART I. Enter the chain of events- diseases, Injuries, or complications -that dnactly 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 it necessary.
<br />IMMEDIATE Metastatic Lung Cancer
<br />disease or condition moulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially. list conditions, if : b)
<br />any; leading In the ease Itetsrh
<br />online e.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter ttie UNDEERLY1NG CAUS£' C)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />:IMMEDIATE CAUSE:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />E; PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not:resulting in the
<br />200f FEMALE::
<br />© Not pregnant Within 1:0 yeai:::
<br />❑ Pregnant et Crane/death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown It pregnant Within the past year
<br />20DATE OF INJURY (Ma., Day, Yr.)
<br />21a. MANNER OF DEATH:::..
<br />® Natural 0 Honititje
<br />0 Accident ❑ Pendlsf Investgetlort
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />denying cause given In PART I.
<br />31b.;IF TRANSPORTATION INJURY
<br />OriveriOperator
<br />0
<br />Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16e. DATE (Mo. Uity VL'i) ;.
<br />November 5 2024
<br />STATE
<br />Nebraska
<br />6880.1`
<br />APPROXIMATE INTERVAL
<br />onset to death .
<br />3 Months
<br />onset to death
<br />onset to death;::'
<br />onset to death,:.:
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />0 YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />T COMPLETE CAUSE OF DEATH?
<br />YES 0 NO
<br />22c. PLACE OR INJURY -At home :farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />Q YES ❑R.0
<br />22f. LOCATION OR INJURY,:
<br />N:
<br />M
<br />$ tte
<br />]at
<br />0.: a.: >.
<br />O
<br />fa a N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP. CODE.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 2, 2024
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />November 42024
<br />;i3d To the:hest of my knowledge, death occurred at the time, date and place
<br />and dueto the dause(s) stated. (Signature and Title)
<br />Ryan Ramaekers, MD
<br />23c. TIME OF DEATH
<br />11:11 AM
<br />2 , DIDT.OSACCO t1SE CON:TeteUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24g::PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOU
<br />HAD
<br />24e,.On the basil of examination and/or investigation, in my opinion death ocatitrad at
<br />"She time, date and place and due to the cause(s) stated. (Signature end Title)
<br />26a. HAS ORGAN'OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />NAME TITLE AND ADDFlESS OF CERTIFIER (Type or Print ..
<br />Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a REGISTRAR'S SIGNATURE 5
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO
<br />N
<br />28b. DATE FILED BY REGISTRAR (hip Day, Yr.).
<br />November 12, 2024
<br />
|