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STATE OF NEBRASKA
<br />t41: HJ , t ISY'C S TiI RA SED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO.
<br />A: TRUE C ? ?VO. T.I C?RIQIIiIAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />S,1/ITAL, RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />131E 0,04t4i4tc
<br />IAIC#LIJ,: NEBRASt
<br />202501 b1 1 304 1,0
<br />SARAH BOHNEFiKAMP
<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 />TA-E' 't TORY, OR:FOREIGN COUNTRY OF BIRTH
<br />NAME (11 r�i It In ksitl0q,,Blve eVest and number)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />6.DATE 9P 1W$ y,
<br />April Z4
<br />e. PLACE OF DEATH
<br />HOSPITAL. Ii Inpatient OTHER 0 Nursing Home/LTC
<br />❑ ER/Outpatient 0 Decedent's Hom1►
<br />❑ DOA 0 Other (Spectty)
<br />Ct7Y, -TCSWN Ol } EA' tI etude ZIP Code) 6d. COUNTY OF DEATH
<br />3rallrl.liancf?8t.:%' Hall
<br />9b. COUNTY /
<br />Hall
<br />,AT riifiEt)F'bEAIH Ea. Married 0 Never Married
<br />mated. j lfdowad 13 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Ile. APT. NO.
<br />9f. ZIP CODE
<br />6880
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Carol K Petzoldt
<br />12. MOTHER'S•NAME (First, Middle, Malden
<br />Gertrude 1 Meinke
<br />dates of seivice If Yes.
<br />112I 9 05/11 /1955
<br />14a. INFORMANT -NAME
<br />Carol K Schroeder
<br />16i, EMBALMERSIGNATURE
<br />BaYlee J McAtee
<br />16t1, CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />NLEiN#1RtE"Af1A'MA LING ADDRESS (Street, City or Town,. -State)
<br />1:231N. 2nd, Grand Island, Nebraska
<br />gTEs€F DEATI
<br />areli 3,.202
<br />6b, LICENSE NO.
<br />1604
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />njuries, or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />, hout showing the etiology. Do NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />CAUSE:
<br />IelOpathy
<br />OR AS A CONSEQUENCE OF:
<br />ASy1t CONSEQUENCE OF:
<br />G,`OR AS A CONSEQUENCE OF:
<br />ITIONS-Conditions contributing to the death but not resultipg lu the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pendin6levesdgetion
<br />❑,uiclde ❑ Could not be determined
<br />TIME OF INJUR'
<br />21b, IF TRANSPORTATION INJURY
<br />❑ orivaeopsrator
<br />0 Passenger
<br />21c. WAS A
<br />❑ YES
<br />21d. WERE AUTI
<br />TO COMNE
<br />0 YES JJ
<br />22c. PLACE OF INJURY -At hot iS, fatm, street, factory, office building, construi tl tl
<br />TRINE HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />Yr.)
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />CITY/TOWN STATE
<br />3c. TIME OF DEATH
<br />11:56 PM
<br />bil kjr><rii!! 0e, detoth occurred at the time, date and place
<br />yYr'!n#As:aitai (s) aNt}M. signature and Ms)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TLM`iDLATH
<br />24e.fM the Witte or examination and/or Investigation, In my epMio
<br />the tlm*, data and place end due to the cause(s) stated. (gigot
<br />Eg#;Qtt... UTETO+THE. DEATH! 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />lid ' `;: PROBAd1 Y ❑ UNKNOWN 0 YES i7 NO
<br />D.:AC ORE S$' RTiP(ER (Type or Print
<br />rVert;;MD, 8533 Prairieview St, Grand Island, Nebra ka, 6880
<br />26b. WAS CONSENT
<br />Not Applies bN H 26s is NO
<br />26b. DATE FILED BY REt3NSIRAIt;(I1i► bey :Y
<br />March 10, 2025
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