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COP*.e.4Rktfi .
<br />CtPYO TH5QR1(
<br />WCESr,''wrAL R `C
<br />A'TE` QI Iv" $UANGE
<br />TATH,OR,i'ER
<br />Bow,, Nebraska
<br />zEGURITYi UMEER
<br />STATE OF NEBRASKA
<br />d7t19p:C/P.f11D�st<:.:.
<br />2tTi'PAAMS.><,�; ;.zasgi4TI'I.CI'P.PCPDdy9s:
<br />tAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO
<br />NAL. RECORD ON FILE WITH rHE NEBRASKA DEPARTMENT OF HEALTH AND
<br />Rt?S OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />9)
<br />20250'f953
<br />SARAH BOHNEN
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH,',
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />Y,'OR FOREIGN COUNTRY OF BIRTH
<br />Cf,l .OEATitide f
<br />Aida'
<br />Owe
<br />et and number)
<br />Ip Code)
<br />is. REEfbENC@,STAT$
<br />'astir ika ...
<br />Myrtle$trtsgt :;
<br />b1AR1?At; STATi1S Al TIME DEATH ❑ Married 0 Never Married
<br />i it ikr asirilNlit [�'YVidowed' ❑ Divorced El Unknown
<br />A ME (FirJf(,' Middle. ' Last, , Suffix)
<br />.rielh.,
<br />I{etl
<br />EVER14'14. ARMED
<br />(Yeti, Nv', or,Unk) Ptii
<br />TA. F IgE1 AL,fi0 NA
<br />€n0stonSoridle
<br />PART
<br />B.a t nllalip list:citn
<br />itirfY ieagitfq4y:tye c�
<br />orslnit.a..
<br />22F, ),OCA
<br />.:D
<br />9b, COUNTY
<br />Hall
<br />es of service If Yes.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />68
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Mule
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Se. PLACE OF DEATH
<br />HOSPITAL ['inpatient
<br />0 ER/Outpatient
<br />( [] DOA
<br />9c. CITY OR TOWN
<br />Aida
<br />HOURS
<br />MINS.
<br />3. DA
<br />No
<br />6. DATE:
<br />July; 1;
<br />•
<br />OTHER ❑ Nursing HomsiLTC
<br />® Decedent's Horne ;.
<br />0 Other (Specify)
<br />ed. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />12. MOTHER'S -NAME (First, Middle, Maid
<br />II Jessie Standlea
<br />14a. INFORMANT -NAME
<br />Kenneth Saner
<br />lee. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />164, LICENSE NO.
<br />1'6cI. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />AND MAILING ADDRESS (Street, City or Town, State) . .
<br />t1(1'.1(ial Home, 601 N. Webb Road, Grand Istand,Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />t
<br />ciadr,_fnlytles, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rflbNMtton without showing the etiology. DO NOT ABBREVIATE. Enter eniy on. cases on a line. Add additional lines if necessary.
<br />lit M ATE CAUSE:
<br />•:;F).Uildetermined Natural Cause
<br />•
<br />ONMO
<br />of
<br />TRAR'A SIG $ n
<br />ASA CONSEQUENCE OF:
<br />olesterolemia, high blood pressure
<br />AS A CONSEQUENCE OF:
<br />IR AS A CONSEQUENCE OF:
<br />1
<br />TCONDIT(QNS.Conditions contributing to the death but not resulting in the underlying cause given in PART I,
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. (F TRANSPORTATION INJURY
<br />© DriveriOperetor
<br />Pssaengr.,r
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />144.' RS
<br />Fathe
<br />16c.t'A
<br />Novg'm
<br />11
<br />21c. WAS
<br />0 yes
<br />21d. WEREE A
<br />TOC
<br />❑YES
<br />2\2c. PLACE OF INJURY -At home, farm, street, factory, office building, cons
<br />BE HOW INJURY OCCURRED
<br />T,iy NUMBER, APT.NO.
<br />Oslo; 'Yr,)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />ccurred'at the time, date and place
<br />ur. and Title)
<br />U 'S THE DEATH?
<br />yA
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />November 15, 2024-
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 12. 2024
<br />.Tint
<br />Uri
<br />2rd. 'IM
<br />06: 1
<br />24e, On the basis of examination andlor investigation, in is
<br />the tare, date and place end due to the cause(.) state
<br />ff Martin Klein, Hall Coun y Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 264. WAS CONS
<br />UNKNOWN ❑ YES ® NQ Not Applicable It 264Is
<br />R (Type or Print
<br />231 S. Locust, Grand Island, Nebraska, 68801
<br />28b. DATE FILED BY
<br />November 1I3,
<br />
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