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STATE OF NEBRASKA
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<br />:WHEN ;THiS.:COPYCARRIES THE RAISED SEAL OF STATE'OF NEBRASKA;1'T CERTIFIES THE DOCUMENT BELOW TO
<br />:. BEA>TRUE,COPYGF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 'DEPARTMENT OF HEALTH AND
<br />`'HUMAN SERiflCES'WTAL RECORDS OFFICE, WHICH IS THE LEGAL' DEPOSITORY FOR VITAL RECORDS
<br />B.
<br />DATE:.OF ISSUANCE
<br />•
<br />6t712024
<br />LINCOLN, NEBRASKA
<br />EG.EDENTS-NAME`(First, Middle, Last, Suffix)
<br />talerttta':IiIltly , Bir'ritt
<br />20250
<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 />CERTIFICATE OF DEATH
<br />4. CITY AND:STATE :OR.TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Stromsb.urd, Nebraska
<br />7. SOCIAL SECURI7YNUMBER
<br />50542-7::19:.;.` .'::
<br />Ste'; FACILITY3NAME:{if'-hot Institution, give street and number)
<br />668 E. Ashton
<br />Bc..GITy::ORTOWN QF:DEATH (Include Zip Code)
<br /><'Grand ls#and68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.; STREET AND NUMSE:R
<br />668;:E. Ashton
<br />9b. COUNTY
<br />Hall
<br />101MARiTAL.STAB S AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11.:FATHER'$41AME meet, Middle, Last, Suffix)
<br />'Bader.
<br />13::.E.VER.'IN:UE: ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />16 METHOD OF DISPOSITION
<br />Bttfial :..:
<br />0'04iiallon
<br />Ctemstion ❑Entombment
<br />01.Removai ` (]:Other (Specify)
<br />53, AGE - L:ast Birtidiiy
<br />(Yrs.)
<br />87.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a. PLACE OF DEATH:;'
<br />HOSPITAL ©.Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 07426
<br />3. DATE OF OEATFi {Eno,
<br />May 25, 2024..
<br />6. DATE OF BIRTH (Mo. Day Yr.)
<br />May 27,.1.936.; ...
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Nome
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Re. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />#bb. NAME OF SPOUSE'(Ftrst, Middle, Last, Suffix) If wife, give
<br />14a. INFORMANT -NAME
<br />Michelle Moeller
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR'OTHER LOCATION
<br />Hospice Facility.
<br />12:MOTHER'S-NAME (First, Middle, Maiden Surname
<br />Elsie : Bloomquist
<br />16b. LICENSE NO.
<br />CITY/TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />lie.:FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All 'F`8ith;S;;EunerafHome, 2929 S. Locust Street, Grand Island; Nebraska
<br />CAUSE OF DEATH (Ste:lnstructio
<br />r1S. and examples)
<br />ft. PART I. Enter the chain of events- diseases, injuries, or complicetions-thet directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one tine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />win DIATE.cAUNE8.1941 ;;.:;. a) Metastatic adenocarcinoma colon
<br />*Hs. ptcoosuion:rtsukin0:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Hat conditions, if b)
<br />any, leading to the cause lifted
<br />n:llaa:s;:::.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eater the UNDERi: YING CAUSE C)
<br />(diliiq>svor Injury That'iiiltietsd
<br />the event resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18:,PART II. 0114 .SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />2o. IF FEMALE:_.. .
<br />�-{ Not pregrfant vithln: peat year
<br />PrednantathaiiiddeatiC
<br />, Not:Pregnefd�t butptegnant within 42 days of death
<br />❑
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown it pregnant within the pest year
<br />'22 c DATS;OF,iNJURy(Mv,; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />(] YES 0 NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide :..
<br />Accident L. .: Paatling Investigation
<br />Suicide 0 Could not be ditenmined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF
<br />21b..IF TRANSPORTATION INJURY
<br />0 Other/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />'YES':'':''
<br />e
<br />14b. RELATIONSHIP T0131»Gi?'pE!}'1
<br />Dsughter
<br />16c. DATE (bttl., Day. Yr.) .::
<br />May
<br />Nebraska
<br />17b ZIp Cade
<br />6S8i1:'
<br />APPRO7
<br />en+n:to d alit .
<br />6Months
<br />oneeatia t blab
<br />onset to death
<br />NTERVAL
<br />11. WAS friEDIOAL El( ENN t
<br />OR COROiJ �F.. 'C!iNTAO?
<br />} YES f NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />▪ YES
<br />21d. WERE AUTOPPSY'FINDiNGSAVAILABLt
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES (. I. N4
<br />t tome farm, street, facto office building, c ..:t;
<br />factory, g, conatwcNoll site;;i�fit
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f:: LOCATION::t;1F.INJURY: STREET & NUMBER, APT.NO.
<br />23a.'DATE OF'DEATH (Mo., Day, Yr.)
<br />May 25, 2024
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 29'';2024
<br />23c. TIME OF DEATH
<br />07:30 PM
<br />t'd. Tuttle bet army knowledge, death occurred at the time, date and place •
<br />and due.tu the tinsels) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />:0 YES::::ioJN0".0 PROBABLY UNKNOWN
<br />C C;S.
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />:11It CODE:..,
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />.....
<br />:24e..Othe finals
<br />' n of examination and/or Investigation, in my opktton ditiitiiO4.1tUnift'At
<br />The:.tinta, date and place and due to the minute) stated. ($)grratursa9 flee►
<br />24d. TIME PRONOUNCED DEAD.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES': RI NO
<br />27a:NAME : Tilt E AND ADDRESS OF CERTIFIER (Type or Print
<br />' RyariD:CrouCh:; <DO, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />lit-2a,17
<br />26b. WAS CONSENT GRANTED?.......
<br />Not Applicable if 26a Is NO ❑ YE$.:.0 to
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 4, 2024
<br />i
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