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<br />STATE OF NEBRASKA
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<br />OP',CARR!I: THE RAISED SEAL OF STATE OF NEBRASKA, IT CERIIYFIES THE DOCUMENT BELOW T
<br />(woo rno,00IQ/NAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />cos, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DE9OSITORY FOR VITAL RECORDS
<br />1R+4netti' Ft "Srler `
<br />AND. STATE'OR TE
<br />l
<br />'202501954
<br />)0
<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 />, Last, Suffix)
<br />ITORY, OR FOREIGN COUNTRY OF BIRTH
<br />•
<br />Dunning„ Nebraska.,•:
<br />f2CIAL SLCURIn!. to,
<br />50840-$i 6 ;
<br />lb. FA+
<br />LfY-NAME (It net institution, give street and number)
<br />206�W. Pine. Street •
<br />CrrY OR TOWN OF DEA'
<br />Aids;e8.81
<br />SIDENCE-STATE
<br />braska
<br />8dd lTR ET AND NUMBER ...
<br />206 W. Pine Street''.
<br />16a. MARITAL STATUS AT TIME C
<br />0 Married, but separated
<br />11.:FATHERS NAME {RNt,
<br />Fred
<br />?VEft'iN.U.3. ARMEm f
<br />nk) No
<br />T5. METHOD OF DI$PoSrnON
<br />• 0 enrisI.... " Ql�pn�ti Ili: :.
<br />a Cr on E1nottibm tht
<br />anotemtint pti a (Spec tA}!)
<br />Code)
<br />9b. COUNTY
<br />Hall
<br />DEATH 0 Married 0 Never Married
<br />lowed 0 Divorced [-.1 Unknown
<br />Last, Suffix)
<br />Ghee dates of service If Yes.
<br />Se. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ fgpatient
<br />❑ ER/Outpatient
<br />❑apA
<br />9c. CITY OR TOWN
<br />Alda
<br />2. SEX
<br />Male
<br />5c. UNDER 1/DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF
<br />February,
<br />6. DATE OF
<br />April 4,1
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />10b. NAME OF SPOUS€TFlrst, ,Middle, Last, Suffix) if wife, glvl maidon
<br />Jessie Standlea /
<br />112. MOTHERS•NAME. {First, Middle, Maiden sums
<br />Myra Cerruth
<br />14a. INFORMANT -NAME
<br />Ronald Saner
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />lid. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />Ill,.FUNERAL: iOMP NAIVE AND MAILING ADDRESS (Street, City or Town, Siete)
<br />1..ittipPlaton.SandarittenifFuneral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />Ec P,ART l..E
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />!sneer.dNunes, injuries, or complicetionsihat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ularfbfllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />S Myocardial Infarction
<br />OR AS A CONSEQUENCE OF:
<br />Italy aft candid
<br />din a to iM cilia
<br />E TO, OR AS A CONSEQUENCE OF:
<br />• BidM thidiNOERLYING CAUQE
<br />thiamine or Injury that Initiated
<br />"Mr" mulling In qN th), • DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)_`•
<br />it. P .RT Ii. OTHER, SIGNIFICANT 0
<br />22d. I
<br />TIO
<br />-Conditions contributing to the death but not restating in the underlying cause given In PART I.
<br />at 4t days of death
<br />pregnant r3 days t01 year before death
<br />art elithId Ibi pant year
<br />URY AT 41ORS?
<br />LINO'.:...
<br />21a. MANNER OF DEATH "
<br />® Natural 0 Honnicide.
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />1BE
<br />216. IF TRANSPORTATION INJURY
<br />❑ nom- Cyx mo,
<br />Pseaenger
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />14b. R
<br />Son
<br />16c. DA
<br />March
<br />19. W1
<br />C
<br />21c. WASAWAUTOP*Yi
<br />0 YES
<br />21d. WEREAUTQP
<br />TO COMPLETE
<br />0 YES
<br />22c. PLACE OF INJURY -At honks, farm, street, factor, office building, constru
<br />INJURY OCCURRED
<br />1ION'OF'iNJUIRT. STREET & NUMBER, APT.NO. CITY/TOWN STATE
<br />234, DATE SIGNED (life., Dsy, Yr.)
<br />23c. TIME OF DEATH
<br />klE
<br />o the be ter( iy kniid/Iedye, deMh tl t the H f`
<br />Cin'ta'iths,cWeefa) stated. pignalum and TRIM
<br />occurred a time, deli
<br />'rift: ,�iknl
<br />Iatthew Alan •
<br />UTE
<br />QBABL
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 6, 2025
<br />24b. TIME
<br />U
<br />24c< PRONOUNCED DEAD (Me., Day, Yr.) 24%
<br />February 27, 2025 - 06;41
<br />and place Rae. On the basis.Of examination and/or investigation, In my awhH
<br />the time; data and place and due to the causeis) stated.,
<br />county)*Matthew Alan Works, Deputy Hall County
<br />TO THE DEATH? 26b. WAS CONSENT
<br />Y ®UNKNOWN Not Applicable If 26a1
<br />ITIFMER (Type or Print
<br />Hall.County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68801
<br />28b. DATE FILED SY ROI
<br />March 10, 2025 ,
<br />26a. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES - I NO
<br />
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