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K STATE OF NEBRASKA_
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKAIT 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 ISSUANCE
<br />10/1112024'
<br />LINCOLN, NEBRASKA
<br />1 DE+~EDENTS NAME> Firrt: Middle, Last, ' Suffix)
<br />Joan .. Mary KYhrt
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />t $O43AL• SECURITY NUMBER
<br />508-54-2836.
<br />8b. FACILITY•NAME Of not Institution, give street and number)
<br />204;;Oherokee Avenue South
<br />EE: co: OR;TOiNtt:Ot 4EATH (Include Zip Code)
<br />Gratrd'.tslaitd `6aeo3
<br />8a. RESIDENCE -STATE
<br /># ' STREET AND;NUMEIER
<br />204 Cheroketi Avenue South
<br />8b. COUNTY
<br />Hall
<br />1041, MARITAL. STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated 53 Widowed 0 Divorced 0 Unknown
<br />FA IiEf{8.-NAME (:fir•ei;:.;; Middle, Last, Suffix)
<br />a. 13. EVER IN U.S. ARMED FORCES? Give dates of service 8 Yes.
<br />(Yes, No, or Unk.) No
<br />18.: METHOQ.AFDISPOSITIQN
<br />fltlrlel,:;, .: DOkt*tIOn::
<br />Crernedon" :' Entombment
<br />Iy ❑ Removal 0 Other (Specify)
<br />SARAH BOHNENKAMP
<br />202501 °71 3' ASSDEPARTMENT OF HEALISTANT STATE TH
<br />R
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIDES
<br />CERTIFICATE OF DEATH
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8.8:::
<br />5b. UNDER 1 YEAR
<br />MOS. '
<br />•
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ;;❑ Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />8c. CITY OR TOWN
<br />Grand Wand
<br />2, SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />2413507.::.
<br />3. DATE OF DEATH t143.4
<br />September
<br />6. DATE OF MIRTN (Mo. Day, Yr:j V
<br />August 5, 18
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />'8d. COUNTY OF DEATH
<br />Hall
<br />8e.`APT. NO.
<br />M. ZIP CODE
<br />68803
<br />0 Oitpico`f. 1,14
<br />wiimp E G+Vf UM(TS
<br />C <vsa
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Lisa Katzberg
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12.:MOTHER'S-NAME (First, Middle, Maiden Sum
<br />Harriet : :::Scarsbrook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />14. FUNERAL HOME NAME:AND MA LING ADDRESS (Street, City or Town, State)
<br />A!t FsitEts;F:utera�H.irrte, 2929 S. Locust Street, Grand Islarr'd:'Nabraska
<br />1613. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instrugtions •and examples)
<br />5. IS. PART I. Enter the chain of events. diseases, injuries, or compticattons4hat directly caused the death. DO NOT enter terminal events such as cerdpe arrest,
<br />respiratory wrest or ventricular fibrllletion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause ona line. Add additional tines if necessary.
<br />>;':'iMMEDIATE CAUSE:
<br />:1MMFp',71ATE CAUSE; (F(nal;'_ : ;.:: ,A) Severe protein calorie malnutrition
<br />these :«:got dnian:taunting;
<br />in death)
<br />eequemlolly list conditlont,,if_
<br />t :Rills.0404to.thsEnure#oeie..
<br />bn linaa>
<br />6:::: Enter the: t 74ttERLYINo CAUSE
<br />p (di or injury that initiated
<br />the events resulting in death)
<br />PST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />rDUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1:8. PART..114OTHER'SIGN(PICANT CONDITIONS -Conditions contributing to the death but not
<br />Post polio syndrome, breast cancer, hypertension
<br />FPMALE:
<br />Pi,:' Hntjlrayn4ht:w)11.j.in tyfar"
<br />0 Pregnant it tipt4ot d idt
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 day; to 1 year before death
<br />• .:❑ un0own.11stio Mintilt(ftn'tite past year
<br />Er*. DATE OFINJURV t
<br />22d, INJURY AT WORK?
<br />❑iNip
<br />o.,(3ay, Yr.)
<br />suit:Main'the underlying cause given in PART 1.
<br />21a. MANNER OF DEATH::';
<br />Natural ❑ Hpmoids
<br />❑ Accident 0 Pending Investigation:
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />::
<br />22r. LOCATION c5t<:tNJI;MFtY. STREET & NUMBER, APT.NO.
<br />ell
<br />23e. DATE OF DEATH (Mo„ Day, Yr.)
<br />Se•ternber 28 2024
<br />23b. DATE:SIGNEO (Mo., Day, Yr.)
<br />e . • r. 0: 2 e 4
<br />QF IN
<br />CITY/TOWN
<br />d ths::106staf:;my;knowledge, death occurred at the time, date and place
<br />'•end'due: to the: csuse(s) stated. (Signature and Title) +�
<br />Chad Vieth, MD
<br />25DI0.TOtkCCO;USE00NTRIBUTE TO THE DEATH?
<br />•
<br />[] YES`;'. N4:;::' ❑ PROBABLY ® UNKNOWN
<br />?. NAME; Tl'!'L ' ND ADDRESS OF CERTIFIER (Type or Print
<br />Y-At he
<br />v
<br />31b.I:FTRANSPORTATION INJURY
<br />DrlverlDyeretor
<br />P014109er
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />sir
<br />14b. REIATIONSHJP TO DECEDENT
<br />Daughter
<br />16c, DATE (Mo<#ftk,Yril
<br />October 8,
<br />;STATE "
<br />Nebraska
<br />17b:ip::
<br />88801:
<br />APPROSUMAT$•INTERVAL.. . •
<br />•
<br />mast to:depthz:'
<br />Months:>
<br />offset to
<br />19. WA8 MEDICAL EXAMINER;.
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21 c. WA8 AN AUT
<br />❑ YES
<br />21d. WERE AUTOPSY•FINCtN¢S A(JAILAft
<br />TO COMPLETE CAUSE OF DE
<br />❑ Yes ❑ NQ';
<br />t, factory, office building, construction sit#, stc:{$(?yt
<br />STATE
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24a.`PRONOUNCED DEAD (Mo., Day, Yr,
<br />24d. TIME PRONG(1Nf>LODEAD 7"
<br />2iNV thi baiis of examination and/or investigation, in my opinion death occpried at
<br />the time, date and place and due to the cause(*) stated. (signature end TWO
<br />26a. HAS ORGAN OR TISSUE pi NA1#ON BEIxN.GONSIDERED?
<br />❑ YES ®NO
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28e. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT ORANTECIi::
<br />Not Applicable if 26a le NO ❑:YES:
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />October 7, 2024
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