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<br />STATE OF NEBRASKA
<br /><errrrn ,T;I:�:..aea silt i rss, +zo.Rtt9'�yiFAvre°"".,�rstt i➢;;:i.evxr q a1 r,
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<br /><;.WHEN<THIS COPY; ARIAIES THE RAISED SEAL OF STATE .OFNEBRASKA' IT CERTIFIES THE DOCUMENT BELOW
<br />EL A`"7'1t t} UE COPY.OF IHE ORIGINAL RECORD ON FILE WIT}l.THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />'` HUMAN SERVICES,' VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />6/12/2024
<br />LINCOLN, NEBRASKA
<br />t•DEGEDEI
<br />Leona
<br />20S0:1998
<br />3104
<br />SARAH BOHNENKAM
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />NMME;(First, Middle, Last, Suffix)
<br />yea';. Thomas
<br />CERTIFICATE OF DEATH
<br />4 'CI:TY:ANO;STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rushville, Nebraska
<br />X'$Ot:1JCt, SEctJRE:'f'Y NUMBER
<br />5a: AGE • Last Birthday
<br />(Yrs.)
<br />8tt FACILITY-NAME(If net Institution, give street and number)
<br />Grend Wand Bickford Cottage L.L.C.
<br />t1c CITY .OR:.TQWN-QF DEATH (Mclude Zip Code)
<br />brand Island;>68801
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />04.:STREET AND .NUMBER
<br />i2 Vla Cvm:o:
<br />9b. COUNTY
<br />Hall
<br />81..
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE:QF DEATH
<br />HOSPITAL 0 Inpiocint
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24
<br />3. DATE OF OEAI `i Mlei 'lilt 1'h ;;';
<br />May,312024 s:#;
<br />6. DATE Otr. Bl1l'Ffi ()No r G111r Syr)>'
<br />August 24, 1,942
<br />OTHER ❑ Nursing Ilome/L
<br />0 Decedent's Home
<br />Ottt•r 0513•CMVASSI$TED LING,,::.
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />1oa :MARn'iitL.'STATI S'AT TIME OF DEATH RI Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.IcilTl{ER:SNAI E.....Flrst Middle, Last,
<br />::Edward: Christian Mortensen
<br />1`S : avar�lll u s. 4311.1ED FORCES? Give dates of service if Yes.
<br />(Yss, No, or Unk) No
<br />16, MEiHOD,OF D(&POSITION
<br />O i et:' ';;`: ❑ D9itAtion
<br />Craitetxn ❑.E.nioiltbmsnt
<br />•Itemoie• ❑-Other(Specify)
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glvs mai
<br />Robert Eugene Thomas
<br />Suffix) 112, MOTHER'S -NAME (First, Middle, Maiden Sum
<br />Joseghirte° Monica McKoski
<br />14a. INFORMANTNAME
<br />Robert Eugene Thomas
<br />111a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />1813, LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR:OTHER LOCATION • CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17R.;FtiNBRAL,HOM;E;.NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ourta:n:Pun ra1'Chapel, 3005 S. Locust St., Grand Island, :Nebraska
<br />CAUSE OF DEATH (See listrul tiods and examples)
<br />1t1. PART 1 Enterthtchein of events- d)eaeaea, injuries, or complications•that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />nepkatory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />iEc rE c i' sE? rti ,(:% .:i. a) Dementia
<br />tri`diiRth)` ,
<br />seoueily lint condMons, if
<br />anr,MOMS to. DIP cves.Ikad
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Multiple Sclerosis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E tt�.t;tii�. UNDERt vlfJf :GAtJSE C)
<br />Idfarasa orinjur thatinlfated
<br />the events resuriirrs M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST .. ........ d)
<br />* FAE T:H.:OTHERSIGNIFICANT CONDITIONS Conditions contributing to the death but not rssultin0In the underlying cause given in PART L
<br />Idiopathic:peripYi4Ta( neuropathy, Neurogenic bladder with chronic fo(ey catheter; Osteoporosis, Hypertension, Obsessive
<br />Compulsive Disorder, History of Acoustic Neuroma
<br />20. (:;FEMALE:.
<br />Ne t.envi' naot within p r* :yar
<br />; t►tiAilan+ds
<br />CI #t#.{rr. neat, but pregnant wfihlm 42 days of death
<br />0 Not Prelimlnt, but pregnant 43 says to 1 year before Math
<br />• unkdovfn f prearnenwierin the past year
<br />CE:0 INJURY tMa, DIY, Yr.)
<br />22d. INJURY At WORK?
<br />❑ YES .0 NO,..
<br />21a. MANNER OF DEATH
<br />El Natural ❑: Homkide..
<br />Accident 0 Pendingtrvutlgagoe:.
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Pabsenger
<br />❑Pedestrian
<br />0 Other(Specify)
<br />dtptes:F#bNlfy:',
<br />IDE.. C(TY` LIM(T$
<br />eat; . srs>'.
<br />•
<br />14b. RELATIONSHIP TOOte t;1 r .
<br />SOOpse
<br />APPROXIMATE INTERVAL
<br />oniNit tb.
<br />.Y4a::
<br />21c. Wit ANAU"t re,,t?ERFpFtMdLt?
<br />❑ YEs<NQ'
<br />21d. WERE AUTOPSYNIID
<br />TO COMPLETE.OAUS
<br />❑ YES ❑. NO, :
<br />22c. PLACE OF.INJURY•At hams,: farm, street, factory, office building, constru
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />22lt;LOCA ION::; ;IFIJUR1x, .S
<br />ET 3 NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />.May 31, 2024
<br />23b. GATE, SIGNED (Mo., Day, Yr.)
<br />..J:une 16402
<br />23c. TIME OF DEATH
<br />08:52 PM
<br />et:TOSteheSt of rty knowledge death occurred at the time, date and place
<br />�9 dufkA lire tawa(s) stated. (Signature and Title)
<br />Kimberly A. Mickets, MD
<br />TO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TUNE
<br />t4ROn the basis of examination and/or investigation, in t rty'aptrti¢h`dr
<br />e tens date and place and due to the cause(Mstated,{8IgndatrI`..:.
<br />Le uru. faxc .c v y31t. 28a. HAS QRGAN,OR TISSUE DONATION:BEEN CONSIDERED?
<br />]`YES"'>': s:> ❑ YES: 1511NO"
<br />T. i14MEz>TI L ANQ;AD1 RESS 6F CERTIFIER (Type or Print
<br />::KlitibeifiA.'Mkiltels, MD, 729 North Custer Avenue, Grand Island,' Nebraska, 68803
<br />CONTRIBUTE TO THE DEATH?
<br />NA, :;❑PROBAeLY 0 UNKNOWN
<br />3813. WAS CONSENT
<br />Not Applicable If 211a Is
<br />28b. DATE FILE© BY RBA
<br />June 11, 2024:;
<br />t'ASt�tL?iHkE
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