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<br />STATE OF NEBRASKA ,,.,.,� ,,,k r;;;•;
<br />ayatggq4fftiio;.. ;.,estrt9d.GidddFS;:s �.azayi4rdP,ytso� „y, (�llillltlt�ll��tt>..
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OPNE`BRASKA >IT„CER:TIFIES THE DOCUMENT BELOW T
<br />0E:44 TRI:JE:COPY OF"THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 'DEPA'ftTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1.1 /6/2024'::.
<br />LINCOLN, NEBRASKA
<br />toaCEDENins-NA010 tfiriti" Middle, Last, Suffix)
<br />Thomas Phillip Kruger
<br />2 0 S>0;::.. ..V': -ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />• :` AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERT1f 1KATE. CIF :DEATH.
<br />4. CITY AND STATE OR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Yankton:,. South :Dakota
<br />7 80;Cl4L SECURITY NUMBER
<br />505'769225:
<br />5a. AGE - Last Birthday
<br />(Yra.)
<br />I
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Graii:d>.Island;Regiona) Medical Center
<br />ec, CITY OR TOWN;1.1F DEATH (Include Zip Code)
<br />Grand Island 68£)03
<br />Se. RESIDENCE -STATE
<br />Nebraska
<br />9d STREETANr;:NiMDER'>.;:
<br />20:4.9.0ass>Rd
<br />9b. COUNTY
<br />Hall
<br />•
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ['Widowed 0 Divorced ❑ Unknown
<br />ERkd=NAiirtE (Ftst' :: Middle, Last, Suffix)
<br />Kruger
<br />13, EVER IN U.S. ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No,rUnk.) Yes 1978-1989
<br />1.0::r.M*tE'THO1 QF DISPOSITION
<br />H:' *I :Muriel::'' ❑ QtiriBtiiir::.
<br />Cremation?;❑:Entoa binant
<br />❑Removal ❑ Other (Specify)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY-
<br />MOS.
<br />DAYS
<br />'Ba:;PLACE OF.PEATH
<br />HOSPITAL :.❑:^Inpatient
<br />® ER/Outpatient
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's_Hotte ,
<br />❑ Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hall
<br />SC APT. NO.
<br />9f. ZJP CODE
<br />68801
<br />3. DATE OF DEAT;f"#Ili.C4:, 0q'/r;
<br />October 21, 2024
<br />6. DATE OF`SIRTN tad•,pay.Yr.j,
<br />August 13,1088:g,
<br />�s'Hpapidr'FaCGi1Y
<br />lob. NAME OF SPOUSE (First, Middle, Last, I Suffix) If wife, give maiden name
<br />Ronda ..:E.rnst .
<br />1:2; MO`rHE:RIS-NAME (First, Middle, Malden Surname)
<br />':::: : I :finery M r. ; /Joanne Angus
<br />::.
<br />14a. INFORMANT -NAME
<br />Ronda Kruger
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCAj1ON
<br />Central Nebras, a Cremation Services
<br />17a' FBNERAL I4QME NAME<AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral. Home, 2929 S Locust Street, Grand Island, Nebr sl a ft
<br />pther.(SaecifY?,' i
<br />'16b,:LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />le. PART I. Enter tlti chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />piratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter Doty one cause one tine, Add additional lines if necessary.
<br />:IMMEDIATE CAUSE:
<br />EDtATE 4A056!' ine)::.<: ,>; a) Sudden cardiac arrest ventricular tachycardia wit ulseless electrical activity
<br />in death)
<br />Sequentially list condit,ons,;if..,
<br />ally; leadinit'tq..ihe cause fisted
<br />•;:till hneA,,
<br />' 'Enter hill l)NOERLYIflt3 cAttaE
<br />t (disease or Injury that initiated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b}Acute myocardial infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Atherosclerotic cardiovascular disease
<br />this events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />dy
<br />tasi
<br />PAi+IT.11.;01140RSIG.NIFICANT CONDITIONS -Conditions contributing to the death butrio,resul(ing in •If underlying cause given in PART I.
<br />Hypertension, chronic kidney disease stage III, morbid obesity, chronic venous insufficiency with stasis ulcers
<br />20 IF FEMALE:
<br />Not:aregtlattt within Gaut �yesF :�
<br />:.:.Q Pregnant,Si time,os de tt€
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />Not pregnant, tout pregnant 43 days tot year before death
<br />Unktiale'n:II prignam v :111tin t)tg,past year
<br />ATE OF413ijpY
<br />22d. INJURY AT WORK?
<br />ay, Yr.)
<br />21a. MANNER OF DEATH::
<br />® Natural ❑ Heitilcidt
<br />0 Accident 0 Pending Investigation'
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />(b.IF::TRANSPORTATION INJURY
<br />{{�-'ylOrin.l'fOperator
<br />Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />14b. RELATIONS
<br />SSPouse.
<br />led, BATE (Mo:';eayF Y;
<br />October 24',,E02.4
<br />1TATE
<br />,Nebraska,
<br />t7tti«;Zip"Cftitr>
<br />68801
<br />APPROXIMA
<br />ORaut to
<br />< 1 HOtr.
<br />On Saj"to it
<br />1 Hoar:.::
<br />onset to.
<br />< 1. Year,
<br />1R WAS;.MEDICAL f ltkpllNER
<br />OR CORQNER:CONTe471'Eb7
<br />1 CI YES NO
<br />21c, WAS AN AUTQPE PERRORI
<br />❑ YES
<br />21d. WERE AUTOPSY FI
<br />TO COMPLETE CAU
<br />0 YES
<br />22c. PLACE OF INJURY -At. host a farttf+Street, factory, office building, construction set
<br />22\s. DESCRIBE HOW INJURY OCCURRED
<br />1
<br />. LOCATION OP INJURY :SINE
<br />T & NUMBER, APT.NO.
<br />23a, DATE OF DEATH 4Mo., Day, Yr.)
<br />October 21, 2024
<br />3i7 AATE;,SiCiS?IEG! (Mo., Day, Yr.j 23c. TIME OF DEATH
<br />0 bar 24,•.2024 05:24 PM
<br />ld...1.#'tile beet of ftiy lelowledge, death occurred at the time, date and place
<br />and due to the taitse(s) Stated. (Signature and Title)
<br />Steven Husen, MD
<br />O;ii?rE C NTI?IBUTE TO THE DEATH?
<br />N !PROBABLY UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TI
<br />240:pRONOJNCED DEAD (Mo., Day, Yr.) 24d. TIME PI
<br />24s; f!n tiia,,he:sia of examination and/orinvestigation, in
<br />the tithe, date and place and due Co the cauae(s) stet
<br />SEJE"DONA;:
<br />:
<br />N ,
<br />TIaN BEEN, :ONSIDERED?
<br />DID TQSAc 26e. HAS ORGAN';OR TIS, .
<br />021ES
<br />NAME TITLE AND ADDRE8a OF CERTIFIER (Type or Print I
<br />Steven Husen, MD, 211E W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28*, REGISTRAR'S:.b1GNATURE
<br />28b, WAS CONSENT GRA
<br />Not Applicable if 26a is NO
<br />28b. DATE FILED BY REGIS
<br />November 1, 2024
<br />AV
<br />A
<br />
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