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STATE OF NEBRASKA
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<br />WHEN Tt1S.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 />DATE OF ISSUANCE
<br />12/13/2024
<br />LINCOLN, NEBRASKA
<br />1.:. UE909.EI T'S IAME..(Firet;:' Middle, Last, Sutflx)
<br />Donald< D iO `Rohweder
<br />4tT4Litet
<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 />CERT!r!9ATE )F EATHH .
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand talent!, Nebraska
<br />S L SECUfii'TY N(I'8ER
<br />505�38-5668"
<br />‘5b. FACIUTY-NAME (If not institution, give street and number)
<br />'' Tabith at:Piair ommons
<br />8C. C(TY QR;TOWNOF:DEA'
<br />Grand:island 68803
<br />9a. RESIDENCE -STATE
<br />8d. STREET:ANNUMEiER'
<br />22 Via Triv�oii'
<br />(Include Zip Code)
<br />6a. AGE Last Birthday
<br />(Yrs )
<br />92
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MO$.
<br />DAYS
<br />8a. PLACEOFDEAT'H
<br />HOSPITAL >❑ Inpatient
<br />0 ER/Outpatient
<br />0 D©l4,'.
<br />9b. COUNTY 19c CITY OR TOWN
<br />Hall ::Gri tid::lsiand
<br />10,5 MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />© Merrjpd, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br /># 1+ FA' HEt 'S NAME (F rs= . j c Middle, Last, Suffix)
<br />Gebrpe; <'' ,:;Bt hv�weder
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />15 METHODD;0 DIS505:01 N
<br />6&lrisi Doti6tihrt.
<br />Glei'tYtttiarY <❑ Enn1 tnb rent
<br />.Q Removal 0 Other (Specify)
<br />HOURS
<br />MINS.
<br />3. DATE OFDP.ATH>(lNei:; DrryYr,)f.
<br />>;;
<br />November 17 24 >';':»;>> .:
<br />6. DAT! OF OIRTH (Mo., Day, Yr.)
<br />July 5 1932'=::
<br />OTHER [] Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Sp,city)A$SISTEt7.`:LlVI#i[+
<br />18d, COUNTY OF DEATH
<br />Hall
<br />IKe,:APT. NO.
<br />9t. ZIP CODE
<br />68803
<br />544
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nuns
<br />Elvera Poehler..
<br />14a. INFORMANT -NAME
<br />Elvera, Rohweder
<br />16e. EMBALMER -SIGNATURE
<br />Katie M. Srnydra
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ella.;: .Meyer
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />17 Y. FUNEam. HOME N .ME AND MA UNG ADDRESS (Street, City or Town, State)':
<br />All FaElths Funerat:Home, 2929 S. Locust Street, Grand Island', Nebr
<br />16b.:LICENSE NO.
<br />CITY / TOWN
<br />Cairo
<br />CAUSE OF DEATH (See instructions and examples)
<br />19 PART I, Error the chain o1 events- diseases, injuries, or complications hat directly caused the death. DO NOT enter terminal events such as cardiac await;
<br />respiratory. arfitet,fir vontri..cular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enttr (nly. Ohs pause en,a line. Add additional lines 11 necessary.
<br />;iMMIEIIATE.CAU
<br />AleeeM/ or eendit
<br />fl.resultjnD >:.
<br />IMMEDIATE CAUSE:
<br />a) failure to thrive
<br />„death) DUE TO, OR AS A CONSEQUENCE OF:
<br />a quest)yxetcorwltiermit:;.. b)dementia
<br />.:.:On tieie:a:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Suter Cite UrriamtI.YINO oAu5f C)
<br />(dimes or Injury that initiated
<br />the event, resulting in death)
<br />E8. PARTIt OTMER.:81GNI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ANT CONDITIONS -Conditions contributing to the death but not:reiuititf((•intS:underlying cause given In PART I.
<br />:FEMALE ..>;
<br />r4et pre(jry1111Pa Ifln j *t year:
<br />{ Pmyran at tlm* of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknownn it P :pen ti Ittiff the past year
<br />M1TE
<br />1N: IUI!tY::(Mtal; Day, Yr.)
<br />21a. MANNER OF:DEATTH
<br />® Natural ❑ 41o411014
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2111.IF:TRANSPORTATION INJURY
<br />0 Onver(Operator
<br />❑`Passenger
<br />❑ Pedestrian
<br />❑ ahar iapeciry)
<br />•
<br />14b. RELATII
<br />Spouse.
<br />Paalllty
<br />oft* UMft'S'
<br />ip TO DECEDENT
<br />10c, DATE (Ma R Oay i : 4
<br />Novenr
<br />STATE
<br />Nebraska.:::
<br />88801 `..
<br />APPROXIMATE'!NTERVAL
<br />OMItit to:dSith
<br />6 Months:;
<br />onset`to dssM
<br />5 Years.;: .
<br />4Y. WAS NIEQICIL>{FXAMINEII'
<br />OR CORONER CONTACTED?
<br />El YES ..®NO
<br />21c. WAS AN AUTOPSY Pe
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGSAVAU,ABLE,
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ vas
<br />22c. PLACE QF INJURY -At ,homs f%MtMist, factory, office building, construction site, Stc ( o
<br />22d. INJURY AT WORK?
<br />EYES: mop;> , <
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />23f. i CAT1t1A1 OF'IN Iu ;STREET & NUMBER, APT.NO. CRY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 17, 2024
<br />22b,;DATE,SI IP,D:,(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />'.140&19(710/'26'.' 2024 07:09 PM
<br />23d>Te thisheMettehtlirtewiedge, death occurred at the time, date and place
<br />anti** to tlur.suse(si stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />28::0113108ACCt3 ?ESE CON
<br />CI�tEt>:; Gt Alt>.<
<br />'1•RIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />27. NAMEg:TITLE:AND Al!). i$ OF CERTIFIER (Type or Print
<br />Ryan 0 Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />246PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOU01CCE0DEAD<>
<br />24eit)n:ttul [iosis el examination and/or investigation, In my ppinlon death d.Cyt
<br />the time, date and place and due to the cause(*) stated (Signature and Titled
<br />26a. HAS ORGAN ORETISSUE DONATION SEEN CONSIDERED?
<br />❑ YES i7
<br />26b. WAS CONSENT GRAN
<br />Not Applicable If 26a Is NO
<br />YES
<br />28b. DATE FILED BY REGISTRAR Mo.,.:Day, Yr.).:'<"':;.
<br />December 9, 2024
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