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<br />!di4) i 1IM �6!i!s'Jdiia€3t")lil 1(1i4W41 ' d; Alb tf((aa.k1i:*lpld!A'E6;46 atiA1,1s?s')0"""u,.aia..�nw
<br />WHEN T`H1S COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERI7FIES THE DOCUMENT BELOW TO
<br />BE: TRUE 'COPY 'OF me ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />1::
<br />a
<br />R %;octo or 1+t..2 24
<br />...3d,'to:11417e t Only, tneWledgt, death occurred at the time, date and place
<br />due`to tte'eilpse(s) stated, {signature and Title)
<br />Steven Husen, MD
<br />25', 101D TOB11GCO
<br />DATE OFISSUANCE],
<br />1 /6/2024
<br />LINCOLN, NEBRASKA
<br />20250345
<br />}(`4.4 J d1 :fikit rat
<br />SARAH BOHNENKAMP
<br />..ASSISTANT STATE REGISTRAR
<br />;. DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE QF: tEA:TH.
<br />1. OEDEDENTE.NAME; (First' Middle, Last, Suffix)
<br />Thomas Phillip Kruger
<br />4, CITY At& STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Yankton, South :Dakota
<br />7SQCtAL SECURITY Ntl:M»ER
<br />503=767922'.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />ea
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />•.:Grand`islat1d gitmal Medical Center
<br />8@. C(T1 OR Tpf N OP q ATh (Inctude Zip Code)
<br />Grand l'eland' 6r at 3
<br />9a, RESIDENCE -STATE
<br />..Nebraska
<br />9d STREET AND?MUMBER
<br />201:9. B:ass:Rd
<br />9t . COUNTY
<br />Hall
<br />ioe. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11 FATHER'S: -NAME (Firat:':. Middle, Last, Suffix)
<br />Rtrbert::;:: Kr'u€e.:>::
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unk.) Yes 1978-1989
<br />5: ME.TI'f013:OF O epOS1TION
<br />❑ Nuriel:<' ❑ Donallort.
<br />� Oregiation ❑•Entarnbrtient
<br />❑ Removal 0 other(Specify)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />tla: PLACE OF.t)E.ATN:, ;
<br />HOSPITAL :DD•Inpgttent
<br />ERJOu patient
<br />❑,DOA:::'::
<br />9c. CITY OR TOWN
<br />Gra•n:d I.sla:nd
<br />HOURS
<br />MINS.
<br />o,l' s
<br />r'I
<br />OF bEATH'.(MAs, Ray Yrj
<br />1, .2.:.
<br />6. DATE OF BIRTH
<br />3. DATE
<br />Oct
<br />August 1
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />6C:APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Muddle, Last, Suffix) tf wife, give maiden
<br />Ronda Ernst
<br />14a. INFORMANT -NAME
<br />Ronda Kruger
<br />lea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER$ -NAME (First, Mtddle,
<br />Mary Joanne Angus
<br />18b: LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION • CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />FUNERAL H3ME NAMEAND MA LING ADDRESS (Street, City or Town, State)
<br />:R Alt Faith:a Funeral:; HomT:ie, 2929 S. Locust Street, Grand island• `Nebraska ter
<br />'' ether. (:S!g�ci f)i )•
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART t, Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />resplretpfy arrest, or ventricular fibrillation without stowing the etiology. DO NOT ABBREVIATE. Enter.only one cause opeptte. Add addaional lines it necessary.
<br />IJ:MMEDIATE CAUSE:
<br />E !k 'a oati'' > :>a) Sudden cardiac arrest ventricular tact cardia:.wittt utseless:e �trical activity
<br />it eptitl'i1ldn,resulttrq.:' ...
<br />in death)
<br />Sequentially list conditions, If
<br />illy; lead fp 13!,the nan1<e Rated:::
<br />'On ilns a..
<br />Enter the iUNDERLVINO CAUSE:
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />I,A8T ..
<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 />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />PART::II.0THER,SIGNI.F'IOANT CONDITIONS -Conditions contributing to the death but no€:resulting. in the underlying cause given in PART I.
<br />Hypertension, chronic kidney disease stage III, morbid obesity, chronic venous insufficiency with stasis ulcers
<br />x(i l:(F FEIYYA(E;, •
<br />;:,.❑ Not:pregniirit tir1dl1i 1?4Ai:Year.
<br />0 Not pregnant, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to'1 year before death
<br />Urtbnown, k. pragaznt!A-41inihe past year
<br />29a. oil;:TE (*INJURY jMo„ Day, Yr.)
<br />22d, INJURY AT WORK?
<br />Q::YEB;:.:[NI
<br />21a. MANNER OF DEATH'
<br />E Natural 0 Hfirnicide.
<br />0 Accident ❑ Pendinp.lnvestipatann`
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE:PFINJ
<br />22e. DESCRIBE HOW INJUttp' OCCURRED
<br />22f. LOCATION ;OF'IN,)URY*STREET& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 21, 2024,
<br />ctrYiTovvN:'
<br />DATE,S(GNEO: NO., Day, Yr.) ( 23c. TIME OF DEATH
<br />05:24 PM
<br />S1b. €PTRANSPORTATION INJURY
<br />priven9perator
<br />i?adetnper
<br />0 Pedestrian
<br />0 Other (Specify)
<br />isty-At:honie,
<br />a
<br />Yr.)
<br />9E et0.E CITY 1 fMtTS
<br />1R Vas ❑ .€so
<br />14b. RELATIONSHMTODECEDENT
<br />Spouse
<br />lac. DATE Moa i ay<'Tr)
<br />Octob
<br />11b Z(p'do
<br />APPfti X$MAT'E(NTBR
<br />16. WAS MEDiOAti*M('NER:
<br />OR CORONER GONT4gteD?
<br />❑ YES ®NO•
<br />21c. WAS AN AUT
<br />0 YES
<br />ERF:t)RM
<br />21d. WERE AUTOPSY FINDIN
<br />TO COMPLETE CAUSE OF
<br />❑ YES ©--..:. s.
<br />A(
<br />(street, factory, office building, construction Site, Stw , iStiO6IfY)'
<br />' STATE
<br />24a.'ATE SIGNED (Mo„ Day, Yr.)
<br />240A!'I N(• UNCED DEAD (Mo., Day, Yr.)
<br />246. TIME
<br />2lgd. TIME P
<br />kg? Pea
<br />2is' of examination and/or investigation, in my opinion .deetti.oefitr
<br />thi terse; date and place and due to the cause(a) stated, meeatuee limitmoo .,
<br />S ... 26a. HAS ORGAN.OR"TISSUE DONA
<br />YES No:
<br />2'I> NAME:' TITLE AND AD RESS OF CERTIFIER (Type or Pnnt
<br />Steven Husen, MD, 2146'W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />E:I«QftITRIBUTE TO THE DEATH?
<br />:;PROBABLY 0 UNKNOWN
<br />REG[STRAR'$.:SIGNATURE
<br />N BE
<br />NSIDERED?.
<br />26b. WAS CONSENTORAHTEDY`'i
<br />Not Applicable If 26s is NO VES'
<br />28b. DATE FILED BY REGISTRAR(
<br />November 1, 2024.
<br />o
<br />STATE OF NEBRASKA
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