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STATE OF NEBRASKA
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<br />WHII N TMS COPY;CA'} RI 'S THE'RAISED SEAL OF STATE OPNEEIRASKAOTGERtIFIES THE DOCUMENT BELOW TO
<br />BE.:ATRUE:'. 't Pl' OF'1: E ORIGINAL RECORD QN FILE WITH tHE'NEBRASKA •.DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA TE'OF ISSUANCE
<br />11 /6/2024>'
<br />LINCOLN, NEBRASKA
<br />��� TSAR H Bo NKAMP
<br />ASSISTANT STATE REGISTRAR,
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />I
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE 9F D•EATH"mi.
<br />:.;:1.:z.DECEDENT$'NAME(Firrti:' Middle, Last, , Suffix)
<br />Tftoma' " Rtfi f " :: r er
<br />a ..... ire.. K ug
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ariktoh:: SOU th::DokD.ta
<br />T.' $ODIAL SOODOSTY N Md;ER
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />lib. FACILITY -NAME (If not Institution, give street and number)
<br />,Grand )SlancfRegional Medical Center
<br />8p: CI.Y:ORTOWN,; OFDE..ATH: (Include Zip Code)
<br />Grind Island 68803
<br />E9a, RESIDENCE -STATE
<br />,,:Nebraska
<br />STREET AND NUMBR .:
<br />2019..Bass Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />Qt ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />whim (F rst;'::` Middle, Last, Suffix)
<br />':Robert.:::;'::'
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />B(Yes, No, or Unk.) Yes-1978-1989
<br />tb..;METHOD'OF DISPOSITION
<br />8uriai'':,
<br />Crtitrration':::EntOeiment
<br />z❑ Removal ❑ Other (specify)
<br />bb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />:8a.:PLACE OF DEATH .:
<br />HOSPITAL E Inpatient
<br />® ER/outpatient
<br />g DOA":
<br />9c. CITY OR TOWN/
<br />Grand )stand.
<br />HOURS
<br />MINS.
<br />it S 1
<br />3. DATE OF DEA`tl,:.' OCtober214C24,
<br />6, DATE OF BIRTH (Mo„ Day, Yr.)
<br />August 13,J1956):
<br />OTHER ❑ Nursing Hama/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />SS, APT. NO.
<br />9f.,Zl CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />:.:Ronda
<br />:.Ernst :.;::':
<br />T:MOTHER'S-NA'ME (First,
<br /><Mary Joanne Angus
<br />14a. INFORMANT -NAME
<br />Ronda Kruger-'
<br />16a. EMBALfJu ER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />171) FUNERAL) otee NAMEAND MA LING ADDRESS (Street, City or Town, Setts) :':::' .:
<br />Funeral<H me, 2929 S. Locust Street, Grand Island;'':: Nebraska for
<br />CAUSE OF DEATH (See instructions and examples)
<br />IL PART I. Enter the chain of events- -diseases, injuries, or complications -hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />..respiratory arreet,.:or vermicular fibrillation without showing the etiology. DO NOT ABBREVIATE: Enter only one cause onr:line. Add additional lines if necessary.
<br />':);;IMMEDIATE CAUSE:
<br />a) Sudden cardiac arrest ventricular tack ...cardii 'with utseless°electrical activity
<br />IMM PLATE CAUSE'IPinat
<br />deenseos_ onditidii:t:sufuiv
<br />In death)
<br />I:eyuantlaliy..,list aonditions,;i( .;
<br />ty; I.°41ti to:The cause tinted
<br />ijy lin4� a'
<br />1:6b:. LICENSE NO.
<br />Middle, Malden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute myocardial infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />ntertl» UNDERLYING CAUS ' c) Atherosclerotic cardiovascular disease
<br />(disease or injury that initiated
<br />the events resulting In death) . -DUE TO, OR AS A CONSEQUENCE OF:
<br />"ST
<br />d) i
<br />1': 1B, PART'II:>OTHER SIGNIFICANT CONDITIONS- ',nditions contributingto the death but iiot.resulting In the under) in cause given In P
<br />Oj g.. Y g
<br />Hypertension, chronic kidney disease stage III, morbid obesity, chronic venous insufficiency with stasis ulcers
<br />IF F:EMAI•P<..
<br />•
<br />:': P.0::Omon*t i1 within rt ket veils.'::
<br />,A[: > ::. ❑ Preghsftt * time f death...;.;
<br />3 .,, 0 Not pregnant, but pregnant within 42 days of death
<br />,i ❑ Not pregnant, but pregnant 43 days`ft1 year before death
<br />�**!!;;�� unkritfwn;If; Pre rnant wititii:I.N; m,.pest year
<br />:: 23if DATE OF INJURY (MO.,.Day Yr.)
<br />22d) INJURY AT WORK?
<br />0 Yes ID NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Hatutcitifl
<br />❑ Accident 0 Pending'Investlgati
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2!'b.. TRA.SPORTATION INJURY
<br />Ohver/Operator
<br />peseeepie
<br />❑ Pedes
<br />❑ Other
<br />22c. PLACE `OP:INJURY-At .home;farm,
<br />:
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />OGATION:OF (N,lURY ::STREET I NUMBER, APT.NO.
<br />23*, DATE OF DEATH (Mo., Day, Yr.)
<br />OCtober21, 2024
<br />3TIk;DATE:StGNED:(Ma., Day, Yr,) 23c. TIIriE`OF DEATH
<br />ober:'24,.:2t324 05;24 PM
<br />32d.^rp the hiett rt rdY:kriewiedge, death occurred at the time, date and place
<br />Fend di/S to th..caitsaIs) stated. (Signature and Thiel
<br />Steven Husen, MD
<br />25.I #atD:.TY: BAOCD G E;C.LIN t iIBUTE TO THE DEATH'?
<br />,h, ❑, YES j>.NO :':❑: PROBABLY ❑ UNKNOWN
<br />27; NAME TI:'rI E INp AtVRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidtey #400, Box 9802, Grand Island, 68803
<br />26t, REGISTRAR'S SIGNguRE ' >•
<br />/7
<br />l_..
<br />❑ iitt ptai'Fa U)ty .
<br />tiyi :Iftsltls O:#:1,Lilyt(TS
<br />thi':ll;ES
<br />14b: RELATIONSHIP TO
<br />Spouse',
<br />16e, DATE (Mont(
<br />October 24, ::2(2.4
<br />"STAY y
<br />fiT0 1p::ce
<br />APPROXIM'ATEI Al.!TERY
<br />onset to
<br />< 1 Ho
<br />:afloat to iltft'
<br />< .1 Hours,,,
<br />to d!N
<br />Year
<br />"wet to
<br />ART I. 19. WAS MEDIC'A.t `.EXAMiN
<br />OR CORONER CONTAC
<br />YES
<br />21c. WAS AN AUTOPSY.P:ERF
<br />❑ YES.
<br />Pedestrian 210. WERE AUTOPSY FINDINGS AVAtt
<br />(Specify) TO COMPLETE CAUSE OF ,DEATH?
<br />sell factory, office building, construction alit, eto:'fBpAgity)"; „
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e.:P
<br />NOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF PEAT
<br />24d. TIME PRONOUN
<br />24atln ttie.bpsie of examination and/or investigation, in my opinion deal;
<br />'the time, date and place and due to the camels) stated. illighatilr end
<br />26a. HAS ORGAN.OR TISSUE s e ATION seEk-OpNSIDERED?
<br />26d. WAS CONSENT GRANTEti ;;;. >;
<br />Nryot Applicable if 26a is NO ❑''ES;,`
<br />28b. DATE FILED BY REGISTRAR j:Mo
<br />November 1, 2024
<br />O'yi'Yr i
<br />T
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