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STATE OF NEBRASKA
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<br />WHEN. THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO
<br />BE A TRUECOPY OF ME ORIGINAL RECORD ON FILE WITH THE NEBRASKA ::DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OOFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />TEiCI1r:IS.. ..
<br />2/5/2025
<br />LISfCOUJ,',NEBRASKA
<br />1; GF,COIENtSfiAI10-11: rs};; Middle, Last, Suffix)
<br />Judy
<br />`� 1; 1T1' A#tO tStq fE of '�TERREroPY, t1R
<br />?tnal►8;<I+Ie13Giska'; :::,
<br />IAL¢ECUftfTY:NUMB R
<br />»6.8'4'f327::>
<br />0, PACItiTv-NAME•(lf not 'neat
<br />Sc? CkTY'OR::TQWN'OFOEpT .0
<br />GYaf i tt:Isla rri `i 688fl 1 ..
<br />fis ,RESIDENCE -STATE •
<br />;:<:.11'18laraska
<br />21.
<br />EE7 q Nf IMHER
<br />20501415
<br />eV? n
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEAT.R
<br />FOREIGN COUNTRY OF BIRTH
<br />ve street and number)
<br />e Zip Code)
<br />9b. COUNTY
<br />Hall
<br />1Oa. MANEITAL STATUB AT TIME OF DEATH ® Married ❑ Never Married
<br />Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Fire > : Middle, Last, Suffix)
<br />ot1 <`
<br />13.'EVER:041).S. A)tMEi3FORCES? Give dates of service If Yes.
<br />Ives, No, or unit) No ,
<br />5:
<br />Ttiggv rlispp p0N:
<br />fttMA.t en ':> ::Eittti [)%ilt,nt
<br />movsl ❑ Other (Specify)
<br />il*, ; kukgeaf;H ►:E NI/At 1L: $AHD laws
<br />JII, Faiths Funert3i: Ho e, 2921
<br />kutl�;(f1niN;:
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH;';
<br />HOSPITAL Q Inpatient
<br />❑ ER/Ou patient
<br />O0A::'
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />10b. NAME OF SPOUSE (Firs
<br />2. SEX
<br />Female
<br />5c. UNDER 1 PAY
<br />HOU S MINS.,
<br />3. DA`t'E :
<br />Foun
<br />6. DATE.
<br />May 1 r
<br />OTHER 0 Nursing Home/LTC Ifti
<br />® Decedent's Home
<br />0 Other (Specify),,
<br />ay, Yr.)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Ile, APT. NO.
<br />9t: ZIP CODE
<br />68801
<br />Middle, Last, Suffix) If wife, give m
<br />Leo Ulmer
<br />13..MOTHER'S•NAME (First,
<br />:AVON . Christensen
<br />14a. INFORMANT -NAME
<br />Leo Ulmer
<br />ea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ADDRESS (Street, City or Town, State)
<br />. Locust Street, Grand Island Nebraska
<br />160.. LICENSE NO.
<br />Middle,
<br />CITY / TOWN
<br />Gibbon
<br />Maiden Surname) •
<br />14b. RELAT OW$NIP TO DECEOver
<br />Silos
<br />CAUSE OF DEATH`tSee instructlorts and examples)
<br />sags; tnludes, or compxcations.that directly caused the death.D0 NOT enter terminal events such as cardiac arrest,
<br />flb$i etion without showing the. etiology. DO NOT ABBREVIATE.. Enter only one cause on aline. Add additional lines if necessary.
<br />EOtATE CAUSE:
<br />Unknown.Natural Causes
<br />DUE TO, OR A>} A CONSEQUENCE OF:
<br />b) Hypothyroidism, Epilepsy, and Hypertension
<br />QUE TO, -OR AS A CONSEQI,IENCIE OF:
<br />DUE TOr OR AS A CONSEQUENCE OF:
<br />1S PAR1' N,:.Q,TttE } $IGN)FI: ANT
<br />!.'.'` F FEMALE
<br />Not; regnsf t *Itrun
<br />25;I
<br />NDITIONS-Conditions contributing to the death but notrelulti
<br />prrYb'tlant,,4td progrNrittaithkn42 days Of death
<br />grant, but pregnant 4; days tot year before death
<br />rti it pf oio viShEr st...pest year
<br />NJURY ATWORK9
<br />errs, ;0:14
<br />04Y, Yr-)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hotnicidtk
<br />❑ Accident 0 Elituhdginvestigation
<br />❑ suicide ❑ Could not in determined
<br />22b. TIME OF INJURY
<br />22c. PLACED
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />., Day, Yr.)
<br />24.b,DATI SIGNED )Mo., Day, Yr.)
<br />CITY/TOWN
<br />.Z c. TIME OF DEATH
<br />:14;theLlie of y..Rti0whdge, death occurred at the elms, date and place
<br />thee4 s thilthitNs) Stated: {signature end Title)
<br />TaBA?
<br />'YES
<br />0
<br />*TRIBUTE TO THE DEATH?
<br />PROBABLY UNKNOWN
<br />NAME;TIT(E AN0 ADDRESS OF.CERTIPIER (Type or Print
<br />28a. HAS ORGAN OR
<br />DYES
<br />n tit#underlying cause given in PART I.
<br />.:21b. 10 TRANSPORTATION INJURY
<br />:t RilverlOperator
<br />0 Paysenuer
<br />Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSj('F(NDINDS'AVA .ARLE
<br />TO QO MPLETE'CIAU$EQF DEATH? -.
<br />❑ YES "'
<br />JURY -At home, farm, street, factory, office building, construction steer; **MR.
<br />$ tom$
<br />aV t
<br />SUE:D(NATION l EN:CONSIDERED?
<br />®NO.
<br />Martin'Ftiein; l'Iall County Attorney, 231 S. Locust, Grand Island, Nebraska,
<br />ilea. RREGISTRA'R'S' SIGNATURE
<br />68801
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 30, 2025
<br />24b. TIME OF MATH
<br />240.PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TI
<br />for a{lar 4.2025
<br />24e; 0)1 ttla;10,i i cf examination and/or Investigation, In my op)n)
<br />the tithe, date and place and due to the caussls) stated. pipnatd
<br />Martin Klein, Hall Coun y Attorney
<br />26b. WAS CONSENT
<br />Not Applicable If 284 is*
<br />28b. DATE FILED SY RE
<br />February 3, 2025
<br />tl
<br />0
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