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STATE OF NEBRASKA
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<br />WHEN TK:rS. COP1*CARRIE$ THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF TKE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />t3ATE.,OISSUAItICE
<br />12/31 /2024
<br />LINCO..i N, NEBRASKA
<br />202501259
<br />la /14 44i 4,4
<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,:DECEDENTS-NAME'(Ftrstfr . Middle, Last, Suffix)
<br />.<Matthei .fames<;::.States
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OFIBIRTH
<br />;:'GTa#1diSI811(llOVSSIO
<br />x: SOCIAL SECURITYNUMBER
<br />505=82=9883'" ' ..
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />10249 Lup River Road W
<br />BCtrC11:Y R TOWN:' IF DEA'E
<br />Dannebraq 68831''
<br />e. RESIDENCE -STATE
<br />. <Nebt asks.
<br />nclude Zip Code)
<br />9q;ST$I .ET ANDNUMHER z: >
<br />;10240::Ewatip;River Road W
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but: separated 0 Widowed 0 Divorced 0 Unknown
<br />1:1FATNER'MleAl::'E (First, '.. ; Middle, Last, Suffix)
<br />Forest.:::: ee:: AStates:::::
<br />EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) NO
<br />16:ME NOC.{1FDlSFosn.0fsi:.
<br />Burial Q3?onntion:'::
<br />Cteiftation DRntonibi tent
<br />❑ Removal ❑ Other (Specify)
<br />• 59'•
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c.,UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF D TN:
<br />HOSPITAL 1:3 tnpetient
<br />0 ER/Outpatient
<br />❑'DOA::
<br />9c. CITY OR TOWN
<br />Dadrreb
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATNIMri'DayYr.)
<br />Found Decembe119, 2024
<br />MI 8. DATE OF RTH (Mo., Day, Yr.)
<br />December 3G>:19i'
<br />OTHER 0 Nursing Home/LTC ❑ FEotpics FaciNt
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />r
<br />IC
<br />e APT. NO.
<br />9f. ZIP CODE
<br />68831
<br />9g,1llfSEpE ' 11`'!>LIM[T$
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Evelyn Daisy, Saxby:.>
<br />12 MOTHER'S=NAME (First, Middle,
<br />;. Twyla: Romaine Stoddard
<br />14a.1NFORMANT-NAME
<br />Evelyn States
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />': `<FUNERA ' 11.(S.04.i7!ME AN D MA LING ADDRESS (Street, City or Town, State)
<br />A1pf++t:Filr rat Honi l,.1123 W. 2nd, Grand Island, Nebraska
<br />11; PART I, Enter tttu
<br />•
<br />reaplrafory..em
<br />MEDE4Tl± GAi
<br />8fiwee ar c rritiwir
<br />Int
<br />1813::LICENSE NO.
<br />1537
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examoiesi
<br />Maiden Surname)
<br />14b. RELATIONSHIP
<br />Spouse
<br />16c. DATE (Mo.,1Ay,1
<br />December 242
<br />DECEDENT
<br />$TATE
<br />ebrallke
<br />17b C048
<br />68601 >;:
<br />nta- di , Injuries, or complications -that directly caused the death. DO NOT enter tennleal events such as cardiac arrest,
<br />vratricuter fibrillation without showing the etiology. 00 NOT ABBREVIATE: Enter ontyone cadiii: on alins,.A.dd additional lines if necessary.
<br />!n dead)
<br />Sequentially,bet condifi troll:1f::
<br />enyl teedi!10't4 1i t ce4a# Its* d
<br />Online a
<br />RLYINS'CAUSE
<br />or injury that initiated
<br />the events resuiting In deathi
<br />UST
<br />1;8 PARTt: O
<br />2O FEiYkitti S..>
<br />_:: ❑ Hdiareedent.wAt efpRa4riire
<br />>❑ Priryt,etil:i1t'NiniF�¢t+ieaite, €.`::
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 42 days to 1 year before death
<br />C1 unkbbeir tt::prelibe t witbitiblif.past year
<br />>.. )Gun shot wound to the torso.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />o)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />T
<br />NOITIONS-Conditions contributing to the de
<br />$2d DA4`E. O iNJU 'W (ktt ii> l7ay, Yr.)
<br />'December 19, 2024"
<br />22d.INJURY AT WORK?
<br />but not:reeuttirt :in the tintlerlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />© Natural ❑ Homicide:!
<br />❑ Accident ❑ Pending Investigation
<br />Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />Unknown
<br />31b. IF TRANSPORTATION INJURY
<br />0 Onveri.Dperator
<br />Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />APPROXIMATE IN'tIiRVAL
<br />onset to conch.;
<br />Unknown:
<br />onattt to deattt►q,;!'.
<br />19. WAS MEDICAL E XAMINEFe
<br />OR CORONER CONTACTED'?
<br />❑ no ; NO...
<br />21c. WAS AN AUTOPSY 'PE F
<br />❑ YES .011 No''=;!;_
<br />21d. WERE AUTOPSY PIN
<br />TO COMPLETE CAUSE
<br />❑YES ❑ NO
<br />22c. PLACE*::QF:INJURY-At holna,'farm;: street, factory, office building, construction
<br />Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Self-inflicted gun shot wound to the torso;
<br />2(; LO ATION:,OF.INJURV STREET4 NUMBER, APT.NO, CITY/TOWN
<br />1024>aI'Vtt! Louis' River Rd. Dannebroa.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />3b PA'rh .S. io:NeD;RMo., Day, Yr.) '
<br />23c. TIME OF DEATH
<br />Iel jd:the:heat of. w 7: tiltoivledge, death occurred at the time, date and place
<br />"'Mind dumb thetauae(s) stated, (Signature and Title)
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 24, 2024
<br />O
<br />24b. TIME OF DEATH
<br />Unknown
<br />AVAILABLE
<br />ATM?
<br />�1PC0t3E::>..
<br />Fe831
<br />24c<FR .:NOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DMA:::#;:
<br />December 19. 2024 10:00 AM
<br />24, Qn the basis of examination and/or Investigation, in my opinion death oceturftl et ...
<br />the time, date and piece and due to the cause(s) stated. (Signature and Title)
<br />Dave Medlin, Hall County Attorney
<br />2a :U)D.TOeAf .w:peg OON'T WUTE TO THE DEATH?
<br />YES'. ❑.... .:.:. OtoEIABLY UNKN
<br />OWN
<br />2T NAMCIetttY AN:P;ADD RESS OF CERTIFIER (Type or Print
<br />Dave Medlin, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26a<:. REGIA.TRAR'S.SIGNATU, RE
<br />26a. HAS ORGAN t7R:TISsuet) QNATION BEEN` CONSIDERED?
<br />❑ YES . . NG1
<br />26b, WAS CONSENT GRANTED?:: :'r?
<br />Not Applicable if 26a Is NO ❑YEs;: ❑;:NO.s":
<br />26b. DATE FILED BY REGISTRAR (Mo,, Day Vr,►:;: `: :.
<br />December 26, 2024
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