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gtiiiwllAA1;'fir;:' 'Middle, Last, Suffix)
<br />STATE OF NEBRASKA
<br />zfrAwfai . fffileritiiiiJSs.._.., <crr!SFd1P.p�cc
<br />or T a[(S COP: Al RI #RAISED SEAL OF -STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />•'EIY' •i'1JR�NtL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />AN SER ICE$,:: iTAL IRECO DS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />2 0 2 5 0 2- 2 9SARAH ' BO M
<br />ASSISTANT STATE REGISTRAR;
<br />DEPARTMENT OF HEALTH' ,
<br />AND HUMAN SERVICES '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERT!FIcATE OF DEATH
<br />2. SEX
<br />Male
<br />TQRYr OR FOREIGN COUNTRY OF BIRTH
<br />at1(alitttl pit, give street and number)
<br />Intdbde Zip Code)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />Sd, COUNTY OF DEATH
<br />Douglas
<br />I* R QENt E TATE ' ` 9b. COUNTY 9c. CITY OR TOWN
<br />IiebtaA'r:':`.t,..`::::.,` Hall Grand Island
<br />AND:NUMB1¢f '>::::::; APT. NC. 9f. ZIP CODE
<br />5I'1<' /dp C) a l :<8t ` .-,- 68803
<br />1t MARITk*' +'li AT1* a Olf DEA'1'!1tii Married ❑ Never Married 10b. NAME OF SPOUSE (Pint, Middle, Last, Suffix) If wife, give
<br />„J.f err buti#p+�r tt ❑.owed 0 Divorced ❑ Unknown Catherine Marie Peters
<br />a of service If Yes.
<br />1 'MOTHER'S -NAME (First, Middle, Maiden S
<br />Mary Dorcas 6adv
<br />14a. INFORMANT -NAME
<br />Catherine Marie Lemmerman
<br />1t1a EMBALMER -SIGNATURE
<br />Andrew D Purcell
<br />d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />.entrar Ne1braska Creation Services
<br />MA LING ADDRESS (Street, City or Town, State)
<br />?eters'Fw er i:l Ht rn a 02 Viand Street, PO Box 181, St. Paul, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See irtstrijctions and examples)
<br />II(aeb, Iniurls, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />1Miitlen without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />EOIATECAUSE:
<br />Gmtorf measures
<br />Stl; AS A CONSEQUENCE OF:
<br />k`septic and cardiogenic)
<br /># AS A CONSEQUENCE OF:
<br />OI! AS A CONSEQUENCE OF:
<br />R.SK:NtFlrr�illt DONDrriONS-Conditions contributing to the death but not resulting in the underlying cause gist in PART I,
<br />0n l ) in9 dancer, atrial fibrillation with rapid ventricular response, acute hypoxic hypercapneic respiratory
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ AcO(dent ❑ Pendllginvestigation
<br />47.awe oldeath
<br />❑ Suicide ❑ Could not be determined
<br />r to fi yaer before death
<br />TIME Of INJURY
<br />22c. PLACE
<br />E HOW INJURY OCCURRED
<br />Ib. IF TRANSPORTATION INJURY
<br />oriver/Oparator
<br />© Pawnor
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />NJURY-At home, farm, strait, factory, office building, cons
<br />21c. WASAN'AIi7OPS* t+
<br />❑ YES
<br />21d WEREA
<br />TO COME
<br />0 YES
<br />BER, APT.NO. CITY/TOWN STATE
<br />23c. TIME OF DEATH
<br />12:19 PM
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e. On the beats of examination and/or Investigation, in my.
<br />the time, date and place and due to the cause(*) steted.
<br />NTRItfUT Tt? THE't1EATH7 26a. HAS ORGAN'OR TjISSUE DONATION BEEN GtiNSIDERED9
<br />;t!ROBA kLy UNKNOWN ❑ YES W NO
<br />fk #kF t R R (Type or Print
<br />I, 98f45U Nebraska Medical Center, Omaha, Nebraska, 68198
<br />26b. WAS CONSENT G1iIAH
<br />Not Applicable If26eIt+NQ
<br />2Sb. DATE FILED BY REti
<br />Februar* 13, 202
<br />
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