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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />SE A TRUE COPY OF TKE ORIGINAL RECORD ON FILE WI?H THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF.ISSUAN E
<br />.12/ `3/220 1
<br />LINCOLN, NEBRASKA
<br />1. AECEGENT?$-NAIYIE {FtrM, Middle, Last, Suffix)
<br />Dua ng :; August '; tupkalvis
<br />202503725
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4. CITY AND 'STATE :O.R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />On a, South..Dakota
<br />xiSOCIIAL 5kObeflY HUMMER
<br />t504444.7161:'::::::"
<br />0 eb. FACILITY -NA Ms'(i not Institution, glue strait and number)
<br />Primrose;, Retirement of Grand Island
<br />c CITY OR;TOWN OF DEATH (Include Zip Coda)
<br />rand (stand; 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska,.
<br />9Q STREET OB lily„ OAR
<br />,.:1990.:ArCcapitalAuenue
<br />.
<br />TO MARITi4L STATUS AtTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1VEATHERS+NAME :(Ffntt, Middle, Last, Suffix)
<br />AUR Ist <:.Il9liiiietn;,: upkaJvIS
<br />9b. COUNTY
<br />Hall
<br />1 `:EVSRIN UAL, itiE((A1rA F ICE$ Give dates of service If Yes.
<br />No, or,Unk) Yes. ,1966-1962
<br />.meTOD.OF Diseibs!1 ON
<br />0oonttton
<br />Gr It sifi# n .11 t t
<br />R rrboval C -Other (Sped y)
<br />Fit
<br />IHHOOtell Welt (F
<br />ssquentla y Hat conditions, if
<br />any,l.ae.....*loth*.CWa .d
<br />tiggir..04: iNtfERLYINtF;CAyli!
<br />(dietiate or InIutythet INWted
<br />dM emote resulting ht dHth)
<br />Ss. AGE - Last Birthday
<br />(Yrs.)
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />So. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />,: 85 .
<br />8.16 P(J PE OP
<br />HOSPITAL:0 npatrent
<br />0 ER/Outpatient
<br />❑ •qQA
<br />9c. CITY OR TOWN
<br />.Grand Island
<br />HOURS
<br />PAINS.
<br />21
<br />3. OATS OP.D._....
<br />Novtbe`r28 2021:
<br />& Oki& Ott iNaTH too., pay
<br />April 15,49
<br />OTHER ® Nursing Home/LTC
<br />❑ Decadent's Home . .
<br />❑ Other (SP•014)
<br />1 8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />204
<br />9f. ZIP CODE
<br />68803
<br />10b. NAMEOF SPOUSE (First, Middle, Last, Suffix) If w(t4, 40Vili; m
<br />Beverly Jean Sherwood
<br />12. MOTNER. S,NAME (First, Middle, M
<br />Elizabeth.: Haverly
<br />14a. INFORMANT NAME
<br />Beverly J Rupkalvis
<br />16a.EMBALMERSIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCA$:1ON ' CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />O t NAME AND MAILING ADDRESS (Street, City or Town State) ;
<br />'JOr..Etil ral Home, 401 Burlington St, Hoidrege Nebraska
<br />CAUSE OF DEATH Mee Instru ctlon9and examples)
<br />chaht grtrwribl- •df/ewp, injurise, or compllcations4hat directly caused the death. DO NOT enter terminal omits such as cardiac inset,
<br />abrigSden wtthuut showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines B noceesary.
<br />IMMEDIATE CAUSE:
<br />a)Prostate cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />'SIGNIFICANT CONDITIONS -Conditions contributing to the death' but not muffing In the underlying cause given in PART 1.
<br />Q;: Not'pI* Y 10
<br />Pntpe jid'tlf:t&n�.g6:ppjgti'
<br />NiA pregn.t, but ptsghant In 42 days of death
<br />❑ Not preg,ent, but pregnant43 days to 4 year before death
<br />upknorin:lf;,1...9100,00Nn a e past year
<br />22* DATE::OF1N,1URY(Mc.Day Yr.)
<br />22d. INJURY AT WORK?
<br />1:I .OYES 0 No
<br />.:.
<br />LOCATION OP
<br />21a. MANNER OF DEATH
<br />® Natural Q.Hdmtcids:
<br />❑ Accident a: Pending lifvrtetiggtlon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b., IF TRANSPORTATION INJURY
<br />1?river/operstor
<br />Payssngor
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />21c. WASA
<br />❑YES
<br />21d. WEREAUTD!
<br />TO CONFLATE
<br />❑ YES.
<br />22c. PLACE ::OF::INJURY -At:hom farm, street, factory, office building, ccnst ueron
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />BMW -STREET i NUMBER, APT.NO.
<br />2xs. DATE OF DEATH (Mo., Day, Yr.)
<br />2021
<br />CITY/TO41F..14
<br />Nhdge, death occurred at the time, date and place
<br />'debited. (Signature and Title)
<br />Rebecca Steinke, MD
<br />26 PlD TOBACCO SE TRI
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.
<br />:2.4e::On the bests of examination and/or investigation at mY
<br />• thVtirrie, date and place and due to the causes) stated.
<br />W.: ,GON BUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 wlr$ :NO s I PROBABLY 0 UNKNOWN ❑ YES ®:NO::: :..<
<br />NAME, TITLE AND A DDRX75S OF CERTIFIER (Type or Print
<br />Rebecca. Steinke, MD, 2118 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />to-44.:17.ss� rc �rz
<br />26b. WAS CONSENT
<br />Not ApplIcabb If 26a Is
<br />D
<br />26b. DATE FILED BY RecestkAR'
<br />December 8, 2021
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