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<br />STATE OF NEBRASKA
<br />wH 'Tr IS COPY CARRIESS THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA'TRUE;COPY.OF THR ORIGINAL RECORD ON FILE WITH THg NEBRASKA DEPARTMENT OFHEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />t
<br />3
<br />DATE OF ISSUANCE
<br />r.'.
<br />G 11/202'�'
<br />LINCOLN, NEBRASKA
<br />202b025.39
<br />SARAH BOHNENKAM
<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 />1, DECEDENT NAME .(First, ::. Middle, Last, Suffix)
<br />WORM :;:::John: Mach'
<br />4' CITY "AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Crete, Nebraska
<br />7 SOCIALSECURITY NUMBER
<br />5066=8568'::
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />Sb, FACILITY -NAME (if not 'Iitstitution, give street and number)
<br />The Heritage .at Sagewood
<br />BC. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand ISland':'68803.:;
<br />Si. RESIDENCE -STATE
<br />Nebraska
<br />9d 'STREET AND NUMBER:
<br />2108 Viking Rd:
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS ATTIRE OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ tknown
<br />11.::PATHER'S-NAME :(First; ` '' Middle, Last, Suffix)
<br />:Cha)ies :>:.:;:
<br />^131 EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or (Mk.) No
<br />16. METHOD OP DISPOSITION.:
<br />513"Burilil Donation
<br />O Creiiutl.:pn ❑ Entombment
<br />❑ Remover ❑Other (Specify)
<br />Give dates of service if Yes.
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH ...
<br />HOSPITAL CI Inpatient
<br />0 ER/Outpa
<br />❑ pm
<br />ER/Outpatient
<br />HOURS
<br />MINS.
<br />3. DATE OF D(eATH;;(Mt1w.
<br />March 2, 2025:==.
<br />5, DATE OF BIRTH (SIC; Day. Ve
<br />September 1;9::1947
<br />OTHER Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify►ASSISTEDVV1
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />IC. CITY OR TOWN
<br />Grand Island
<br />Di. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. oospo 'GrYY LIMITS:,
<br />Et)**>IQ; M .
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name,
<br />Dianne Bartek
<br />14a. INFORMANT -NAME
<br />Dianne Mach
<br />16a. EMBALMER -SIGNATURE
<br />Timeree L Andreasen
<br />16d. CEMETERY, CREMATORY -OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />12, MOTHERS.NAME (First,
<br />Doris .::Muff
<br />16b.LLCENSE NO.
<br />139a
<br />77# FUNERAL.HOME NAME:AND MAIUNG ADDRESS (Street, City or Town, Steel
<br />Livingston-Soridermmiant'I.;:Funeral Home, 601 N. Webb Road, Grand. island, Nebraska
<br />Middle, Maiden Sumants)
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE QF DEATH Mee instructions andexamDles)
<br />1a. PART I. Enter the chain of events- diseases, injuries, or compticationsdhatairrectiy caused the death. DO NOT enter terminal events s�h as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />::NNMEDIATE CAUSE:
<br />iMt EDu 'mccvsE (Drab . *"Unknown Natural Causes 1;
<br />..disease orcondHMn resultingin '
<br />death) •DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any:Madhw'tn tir uuw:)iatr d;:
<br />on lltts a. {LIE TO, OR AS A CONSEQUENCE OF:
<br />Entert . UN pERt.VIN4:CAUSE:: C)
<br />Ones, or injury that Instated
<br />the events resultag in death)
<br />LAST /
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18:. PARTIL OTHER BIGNIFICAN CONDITIONS -Conditions contributing to the death::but not re.
<br />IZheimers Cleanse, Epileps} Hypertension, Hypercholesterolemia,
<br />.20. If FEMA),E:.,
<br />Not-:angnaft ;wi hin;pastyNv
<br />Not piepihnt, but'pisgnsitttiithin 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />vnnarm.ifpregn fitwtthiethe.pastyear
<br />EWOAT OFItigURTINIi Orly, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES..::.❑ NC .:
<br />21s. MANNER OF DEATH
<br />® Natural ❑ Hoinicid.
<br />❑ Accident ❑ Pendingtnveatyiflon
<br />❑ Sui)de ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY At ft
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />j OCAT{ONOF INJURY: STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />iny<inthe:unde lying cause given In PART I.
<br />21b. IFTRANSPORTAT►ON INJURY
<br />...❑ Driveriniitrator
<br />.:�a'.0
<br />QPedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP`TO DECEDENT
<br />lwrfe
<br />18c. DATE (Mit, Bay, Xtyl::;:
<br />March 6, 2028`:':
<br />sTATe
<br />Nebraska
<br />17b.;ZIp Ca to
<br />688Q3/
<br />APPROXIMATEI1TERVAl.
<br />onset to de tit
<br />onset to AsaEt
<br />19. WAS MED(CAGEXAMINSi:::":'
<br />OR CORONER CONTACTED;?
<br />al YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ei NO`::"';:
<br />21d. WERE AU
<br />TO COMPLETE CA
<br />❑YES ❑N
<br />e;:;Mfirt,:Street, factory, office building, construction
<br />STATE
<br />(S
<br />AIAEAmu'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Me., Day, Yr.)
<br />23c. TIME OF DEATH
<br />r:.:•:. TD:the bist bfriytknowledge, death occurred at the the, date and place
<br />::.crud duti4e::t!»' Cltigal(a) stated. (Signature and Title)
<br />25. IRO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />::❑ YES :;❑ NO:;; ' ❑ PROBABLY El UNKNOWN
<br />26a. HAS ORGAN
<br />❑ YES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 4, 2025
<br />24b.TIME OF DEATH
<br />Unknown
<br />21c .PRONq(jNCED DEAD (Mo., Day, Yr.)
<br />Marc)24d. TIME PItONOIN
<br />l: ' 028 01;42 AM.
<br />44s. 01ithe:t lsts of �xaminatt6n ind/or im risOW*gatlon, In my opinion d
<br />"t a timo date and place and due to the cause(*) stated. 4$)gnntpre
<br />Martin Klein, Hall County Attorney
<br />• . TION:aEEN CONSIDERED?'
<br />7;I iAME 1IT4eAND.AD TRESS bF CERTIFIER (Type or Print .
<br />Martin 'Klein, i all Cai my Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />25b. WAS CONSENT
<br />Not Applicable if 26e Is NO
<br />28b. DATE FILED BY REeIs RAT! (M ,,'Day�.Yrd
<br />March 5, 2025
<br />
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