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STATE OF NEBRASKA
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<br />S COPY CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW To..
<br />COPYOFME ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />ERV/CES,VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />its8UA;lu.CE
<br />4/112025
<br />'<>`i;:; ,.
<br />uticatti6 NEBRASKA
<br />f1
<br />!" E DENT .S;.NAMAE'11=ii1t Middle, Last, Suffix)
<br />Etiiiva:r :lay VatxtflCinkle
<br />4: CITY AND STATE O•RITTR'T, OR FOREIP,N COUNTRY OF BIRTH
<br />202502020
<br />>.:HaiI;:c cunt , Nebrsska
<br />I>`SO (M. SECURITY'NWW4 ER
<br />SARAH BOHNENKAMP'
<br />ASSISTANT STATF4REGIS'1I1
<br />DEPARTMENT OF HEAL,T
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Bb.'FACI,LITY-NAME (If not Instltutlory'ylve street and number)
<br />:}''';407; Berber' ': i ..
<br />:TOW Ot?'Rffi7#I (Include Zip Code)
<br />8824..
<br />Yrr. RES)DENGE•ST
<br />Nebraska
<br />54 $ t RlE7' AND ;NUIN
<br />d(7Berber ` ::
<br />ATE:
<br />9b. COUNTY
<br />Hall
<br />0*. fiMARITAL STATUS AT TIME Of DEATH ® Married 0 Never Married
<br />rated tjWldowed 0 Divorced ❑ Unknown
<br />11 FA'VHEtt+. ROBE. (F rst,' .Middle, Last, Suffix)
<br />C)!11)on V8tla%Inkle`
<br />VER IN
<br />S. ARMED FORCES?'Blve dates of service If Yes.
<br />Unit.) Yes 08/06/1951-08/05/1969
<br />1s;,MIE,THODOF DISPOSITION
<br />:8w1161
<br />Cremation';QEntoy bme
<br />❑ Removal . t3 Other (Spec.
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />8;3::
<br />5b. UNDER 1 YEAR
<br />Z. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />M
<br />DAYS
<br />Se. PLACE QF HEATH:
<br />HOSPITAL 0:trip4tient
<br />0 ER/Outpatient
<br />;0 DOA:.::
<br />Sc. CITY OR TOWN
<br />Cairo
<br />HOURS
<br />MINS.
<br />3. DATE t
<br />Februa
<br />5. DATE
<br />JartU
<br />OTHER 0 Nursing Honis1LTC
<br />® Decedatt's Home
<br />0 Other(Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Pe. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />10b. NAME 9F SPOUSE (First, Middle, Last, Suffix) If wife, give niait)ait
<br />Judith Ann . Have . .
<br />12. MOTHER'S -NAME (First, Middle, Maiden
<br />'Pear{ :,14linkacek
<br />14a. INFORMANT NAME
<br />Judith Ann VanWinkle
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />14d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />'17# FONER. MCfARE NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br />; isAUU a l s Furapotl-t me, 2929 S. Locust Street, Grand Island,>N.ebraska
<br />In death)
<br />re*
<br />sixLICENSE NO.
<br />1.397
<br />CITY I TOWN
<br />Cairo
<br />CAUSE OF DEATH (See instructions and examples)
<br />vents -.disuses, hippies, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rfil ttaiti n without showing the etiology. DO NOT ABBREVIATE„Enter only one cause on aloe. Add additional lines B necessary,
<br />':.IMMEDIATE CAUSE: .
<br />s)Chronic Obstructive Pulmonary Disease .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Mhytterttiattytea cogdittorNt,:![.;. b)
<br />:409. iaeof pi)tio:.}he 4000.
<br />palm :it
<br />Enter the tiiibEitiAll a O40,98
<br />idiom or injury that Initiated
<br />Ug TO, OR AS A CONSEQUENCE OF:
<br />the svernrresulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8BIGN.1.IICANT,CONDITIONS-Conditions contributing to the death but: not resulting. in the::underlying cause given in PART i.
<br />Sze. tfftTE 0.Ks JU14Y
<br />Z�.
<br />ia�.o'ia;,;
<br />URY AT WORK?
<br />■yes or a■th
<br />ear before death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investlgetion
<br />u Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b,::MF:TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />lac. DA1
<br />1
<br />onset
<br />19. WAS
<br />OR CORD
<br />❑ Yea
<br />21c. WAS AN A
<br />[3 Yes
<br />21d. WERE AU
<br />TO COME1
<br />❑ YES
<br />22c. PLACE ©F INJURY -Al home, farm, street, factory, office building, construC8on lit►,
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />AT!L fe S1F:li4J 1pY`'S
<br />NUMBER, APT.NO.
<br />23a.DATE OF 13 TO (M'o., Day, Yr.)
<br />..230..I1ATE::. IGNED: Ito, e Yr.)
<br />23c. TIME OF DEATH
<br />ti obit ti:iss r f.tn 91noNAodga, heidl occurred at the time, date and place
<br />'and ddiitotttscIttays) eta,. (SigrAturs and Tttte)
<br />i
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February'27, 2014
<br />24b. TIME
<br />11.:00 F
<br />240.:PRONFOUNCED DEAD (Mo., Day, Yr.) 24d. TIMEM.t
<br />\� a
<br />Februfry 26. 2014 ,11:4
<br />2As. C)tt �Hfstiipis of examination and/or Mvest k1Mb0. in my oplMWt
<br />the time, date and place and due to the cause(s) Mayd. Neseattw
<br />Dave Medlin, Hall Deputy County Attorney
<br />AitRIBUTE TO THE DEATH? 26a. HAS OR M+1 OR lissuE r • A?IQN:BEEN CONSIDERED? 25b. WAS CONSENT
<br />8;:: !❑> NO >': ;' 'PROBABLY rya UNKNOWN ❑ YES :: ::i "i 1ZI NO Not Applicable If 25a is NO"'
<br />1110,E;fcrl *OPRE$S OF, 'CERTIINER (Type or Print
<br />Medlin; t1atl Deputy County Attorney, 231 S. Locust, P.O, Box 367, Grand Island, Nebraska, 68802
<br />28b. DATE FILED
<br />February 28,
<br />
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