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<br />STATE OF NEBRASKA
<br />;etaitltl'P,P(I loss,
<br />alI1.9.71�CPi11Dg•`,::w/,Irrytp� 1.
<br />!1flIS CoPYCARRIjs.THE RAISEO SEAL. OF STATE OF NEBRASKA, IT CE,RTYFIES THE DOCUMENT BELOW tO
<br />A:TRUE;COPY ;O: THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ;DEPARTMENT OF HEALTH AND
<br />HUMAN SF,1"VICES, VITAL, RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />3/14/2025
<br />LINCOLN, NEBRASKA
<br />•EOED,EN "t)-NMiE
<br />lames:< OSENSh° Ftt Cka
<br />20250(1660`
<br />SARAH BOHNENKAMPy
<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 />Last, Suffix)
<br />CITY TE'OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />::antral::iCity,:... braska.
<br />OCW7ir. SECURITY NuMEEft,
<br />AND STA
<br />street and number)
<br />c::.CITY:OR TOWN OF DEATH (Include ZIP Code)
<br />C3rarJ'(slnl<t38Bt,3.'' "
<br />RESIDENCE -ATE
<br />.Nebraska
<br />8?I EE1 AN..D NUMBe ";;
<br />ti4TifaueldribharriiiDriVe .
<br />9b.000NTY
<br />Hall
<br />Os. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />ME> tFirat : MMddts Last. Suffix)
<br />RIM S. AfdNEC
<br />it, NO, or Unk.).No
<br />RC
<br />MrETMOD:G:F DISPOS(Ttpt#...
<br />EIurlal :z: 7 onatlon
<br />I�..
<br />R.movei_ ❑mot,r(SpadN)
<br />ve dates of Service if Yes.
<br />5a. AGE = Last Birthday
<br />(Yrs.)
<br />79
<br />56. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8a. PLAcs:.os
<br />HOSPITAL CI inpatient OTHER-0 Nursing
<br />ER/Outpatient
<br />❑ p 0 Decedent's HMI*'
<br />❑:DOA :: ;:: ® Other (Specify
<br />3. DATE OP
<br />March'
<br />8. DATE
<br />June 12,
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />+Grand Island..
<br />5e,.>APT. N
<br />10b. NAME OF SPOUSE(First, Middle,
<br />Lola Mundt I
<br />12, MOHER'S�NAME (First, Middle, Malden Surname)
<br />Mary : .Kucian
<br />14a. INFORMANT -NAME
<br />Lola Ruzicka
<br />tea EMBALMER-SIGNATURE
<br />R. Curran
<br />0. 9f. ZIP CODE
<br />68803
<br />Last, Suffix) If wife, give maiden
<br />1eb. LICENSE NO.
<br />1092
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION :: . . CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />:FUIIERA.HOM : NAMt AND MA LING ADDRESS (Street, City or Town, Sta10)
<br />ur'an Fu(ler8'i Ct apel 3005 S. Locust St., Grand Island, Nebraska
<br />T I. EMelt
<br />CAUSE OF DEATHiSee instructions and eYlamDies)
<br />iilsasaf, (niuries, or complications -that directly caused the death. DO NOT enter terminal events Much as cardiac arrest,
<br />n without showilpMthe etiology. DO NOT ABBREVIATE. Enter only one caws on s line. Add additional lines N nasssary.
<br />TE CAUSE:
<br />Alzheimer's Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />. Sequentiallylai.sondiions,if b)
<br />aalp:seatinptoteSCaus:elisted
<br />on:llila.ii'.' "
<br />.ti
<br />ii'Ierti etilat2S Ylita,CAUSE'
<br />Sienese or injury that (nmated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />svbete insulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />IT d)
<br />It :PART 11,OTHER:_StO! IIFICiikNT
<br />EMAILE
<br />Napregt!setiethifnp 'in
<br />regnenta dineaddH
<br />Of pirgiiillt bUlyrsgnafitWRhie a2 days of Oath
<br />Potinant. PlattnanfaaallYatotyearbarondeath
<br />touti itpM{ I.na W*idnihl.put year
<br />14b, RELA
<br />$00
<br />18c.;DA'
<br />March °14
<br />f7b,
<br />DtTlONS-Conditions contributing to the death but Mat.rB$Ulting in the underlying cause given In PART I.
<br />0EOF000IY(rl44Day
<br />Y AT WORK?
<br />8....ONO-
<br />21a. MANNER OF DEATH .
<br />Natural 0 Homicide .
<br />0 Accident 0 Pending Investigation'"
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAOE GF INJ
<br />INJURY OCCURRED
<br />NUMBER, APT.NO. CITY/TOWN..:
<br />F DEATN (Mp„ Day, Yr.)
<br />March 7, 20. 5
<br />.:DATE S.IG 1ED(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />ri)rtts!iit ,2025 09:13 PM
<br />:0:1*.botormy.iinewloriso, death occurred at Om time, date and place
<br />dell dna tatle;c treats) stated. (signature and Title)
<br />8iry L Settle,MD
<br />TO THE DEATH?
<br />Y UNKNOWN
<br />AbaRksa or CtFIT1 ER (Type or Print
<br />D, 416 N Diers Ave, Grand Island, Nebraska, 68803
<br />ATURE
<br />lib. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Q PastSnper
<br />O Pedestran
<br />0 Other (Specify)
<br />21c. WAS AN AU
<br />❑ YES
<br />21d. WERE AUTOPSY PI
<br />TO COMP:
<br />❑ vas
<br />Y-At hame,.farm;: street, factory, office building, construcUonf
<br />V
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PROMOUNCED DEAD (Mo., Day, Yr.)
<br />See Co tire.basis of examination and/or Investigator, in my Opinion.dp
<br />die tlute, date end pace and due to the cause(*) stated ( IgdMWrti
<br />24d. TIME P
<br />28e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES : INO:;::
<br />28b. WAS CONSENT
<br />Not Applicable if 28a is
<br />28b. DATE FILED BY REGIS
<br />March 13, 2025 �,
<br />
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