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<br />STATE OF NEBRASKA
<br />r,Gtrt4444M8ssa•••.e¢ttfft.B,i�Pf.N1JSc•°>•:,•g476rA'CdlDxsc .;•kttit9.9:.1�.Cl�s,:�i::.`ggarri
<br />E1 THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERflFIES THE DOCUMENT BELOW ,Ti
<br />A TRUE COPY OF TIlE ORIGINAL RECORD ON FILE WITH THE NEBRASKADEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />SATE OFiss(mC =
<br />a/7r2025
<br />LINCOLN, NEBRASKA
<br />'1 bseeDeer I (14ME : F(rst;i . Middle, Last, Suffix)
<br />•
<br />Peter:: <;a) ly <<Krwse
<br />202501915 /d &idue2
<br />SARAH ROHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERT1FIRATE OF 4EATH
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY Of BIRTH
<br />7'.SOCIAL SEct#RITY HUMMER
<br />505=52:46(*
<br />&b. FACILITY -NAME (If
<br />of Inetl
<br />give street and number)
<br />CHI: Fiealtl $t. Francis
<br />. CI.Tt? OR: Tii N:'Off A F1(Include Zip Code)
<br />Grand>i3larre> 66603'.
<br />9a. RESIDENCE -STATE
<br />.,Nebraska
<br />44100 ET'. Np'Ai{liYl#gt7:' `'
<br />257 Sts'Pattl: Fiiad
<br />96. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marrldd 0 Never Married
<br />0 Married but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11 FATHER:S-NAME tfiretr'<': Middle, Last, Suffix)
<br />Percy Milton ';)ruse>
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />.15.: METttpo OF<D(sPoerri QN
<br />rlat''s: >`:❑ DOn tiai.
<br />»I.metIon Entomb lent
<br />temovel � El Other (Specify)
<br />5a. AGE Last Birthday
<br />(Yrs )
<br />83::.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male]
<br />-1c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH:::
<br />HOSPITAL ..:Inpatient
<br />0 ER/Outpatient
<br />CI DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OS DE
<br />arch _ . .
<br />6. ATE OP ell Th (Mt
<br />October 7
<br />OTHER 0 N tirsing Home/LTD
<br />❑ Decedent's Home'
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />/
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Denise Rae Larsen
<br />12, MOTHER'S -NAME (First, Middle, Maiden ),
<br />Frances ::..:'Molynea ux
<br />14a. INFORMANT -NAME
<br />Denice Kruse
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran /
<br />t6b. LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a F 1ERA4 HO ME $NAME:AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran FwlerMI C aped 3006 S1Locust St., Grand Island, Nebraska'
<br />rn
<br />#tract, or
<br />elATE4A (lrip•l` :.'. . .
<br />Sea or.:aanaitior r s :
<br />' Segpentially Ilat fOnditions, if
<br />>:;I*Iy; ia*pti ag to titl.6%lv.. �NaIad<::
<br />`4n Sni*.•
<br />',Eniar th l.SUN RLN lNo c1 78I
<br />(disease or injury that Initiated
<br />CAUSE OF DEATH (See instructions and examples)
<br />chain of awnts: .diseases, Injuries, or complicatione4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, //
<br />f{WiiMtion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necetsary.
<br />IMMEDIATE CAUSE:
<br />Icute respiratory failure with hypoxia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)aspiration pneumonia /sepsis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) acyte ischemic stroke
<br />the awnta resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST :..' d)
<br />"1.9. PART.1
<br />chronic
<br />'iTHEKR6IflNIPCANT CONDITIONS -Conditions contributing to the death but not
<br />ongeSti a heart failure/chronic obstructive Pulmonary Disease
<br />0.4F FgM;r :
<br />Net preytilnt:IN t)�,tm
<br />�^^� Pragnuis:4t tktli rr (malh
<br />.❑ Not pregnant, but pregn tit wit in 42 days of death
<br />❑ Net Aregnant bot pregnant 41 days to i year before death
<br />Q Ufihnown, lr pregnant ititltt he past year
<br />Its. DATE OFINJ IRY flosi. 4iay, Yr.)
<br />22d, INJURY AT WORK?
<br />DYES 0;N4
<br />Y
<br />ultin
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide.
<br />❑ Accident 0 Pending Inveatigatlon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />In
<br />underlying cause given in PART I.
<br />.21b lF TRANSPORTATION INJURY
<br />El Driver/Operator
<br />:%❑ Passenger
<br />❑ Pedeetnan
<br />❑ Other (Specify)
<br />16c. DATE (
<br />April 7
<br />1?b
<br />6
<br />APP
<br />F' Ofittlttod/.
<br />4
<br />onset,
<br />4 Days:...
<br />onset
<br />14D
<br />A
<br />Yl
<br />21c. WAS AN AUT
<br />❑ Yea
<br />21d. WERE AUTOPSY pm
<br />TO COMPLETE CAUSE
<br />❑ Yes
<br />22c. PLACE OF INJURY -At home, farm, .surest, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ATION OF:INJiURY_ ;STREET & NUMBER, APT.NO.
<br />23e.. DATE OF DEATH (Me., Day, Yr.)
<br />March 31, 2025
<br />23b. DATE,SIGNEI into., Day, Yr.) 23c. TIME OF DEATH
<br />05:17 AM
<br />2*. T . the" $st 4►nty knowtedge,`deeth occurred at the time, date and place
<br />' nd:dtt to theetivae)$l stated (Signature and Title)
<br />Jana G Van Wie, MD
<br />DID;?iDBACCO [#S!CONTRIBUTE TO THE DEATH?
<br />❑i::PROBABLY 0 UNKNOWN
<br />NAME, ' )TL AND 4l DRESS OF CERTIFIER (Type or Print
<br />G Van We, 3563 Prairieview St, Ste 200, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME -OF DEATH
<br />240:,PRf#NOUNCED DEAD (Mo., Day, Yr.►,,24d. TIME PR
<br />24g.'On 5hh,beeN of examination and/or investigation, in my,opinion
<br />the dini, date and place a7 due to the caueepl stated. (61gn•ttlq
<br />26a. HAS ORGAN OR TISSUE `DONA. ON BEEN CONSIDERED?
<br />❑ YES ®NO:
<br />25b. WAS CONSENT
<br />Not Applicable if 260 1s NQ
<br />2Bb. DATE FILED BY
<br />April 4, 2025
<br />ttt
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