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<br />STATE OF NEBRASKA
<br />d¢ka6117t;1;P.P.Ilpss., rrtaW
<br />BEN: IS C CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELO
<br />EsA°;T i'UE: OPY:OFF THE ORIGINAL RECORD ON FILE WITH THE..NEBRASKA DEPARTMENT OF HEALTH AND
<br />OWES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS \
<br />Et ' -NAME
<br />n R s:Kohler' .'
<br />STATE OR TERRITORY, 0
<br />;:COiUtnti3t15, Nebraska.:..
<br />5
<br />iscuai Y
<br />915 >'
<br />.ER
<br />Sb,'FAClLfTY•NAME(►f not Instlhrtion,
<br />CHI.:HSalth St..Fran.cis.
<br />84. cirtoR' OIIV
<br />202503801
<br />SARAH BOIINENKAMP
<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 DEATH:.
<br />e, Last, Suffix)
<br />R FOREIGN COUNTRY OF BIRTH
<br />sheet and number)
<br />DEATH :(Inch zip Code)
<br />/Grand::Island<: 6880" I
<br />ENC&t4TATI
<br />eke ........
<br />9d sTREET: N MtiE1t i <::
<br />' 920 Sag od:
<br />AR.A• STATUS AT TIME
<br />Mrfriedr but as
<br />T iERIii NAME (First,
<br />Kohler
<br />(J,S. AaatED"FORCES?
<br />t+i unk) ND,
<br />14 •MET OD OF D SPOSIDON
<br />Bt tal 0 Don'tfo i is
<br />Oraamsuon DEntiOmuiitlnt
<br />QR'emoval ❑OOth.r(SplOo
<br />9b.COUNTY
<br />Hall
<br />TH El Married ❑Never Marrled
<br />d i_t Divorced \ 0 Unknown
<br />Last, Suffix)
<br />dues of service H Yes.
<br />5a. AGE Last Birthday
<br />(Yrs )
<br />8Q:.::..
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />sa. PLACE OF DEATH
<br />HOSPITAL , (.:Inpatient
<br />❑ ER/Outpatient
<br />❑.:DOA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE GF
<br />Febrl
<br />5. DATE
<br />Se00n
<br />OTHER 0 Nursing HonrILTC
<br />❑ Decedent's Homo
<br />❑ Oily► (91,19194 •
<br />IBd. COUNTY OF DEATH
<br />Hall
<br />iti► APT. NO.
<br />202
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Margaret
<br />Scritthfleld
<br />13. MOTHER$.NAME (First,
<br />Irene Booth
<br />MEd. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Schuyler Cemetery
<br />1za::;FUNERAL HOME NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br />; aiths Funeral :Horne, 2929 S, Locust Street, Grand Island,°Nebraska
<br />lib. LICENSE NO.
<br />'1071
<br />Middle,
<br />CITY / T,1 WN
<br />Schuyler
<br />Maiden S
<br />CAUSE OF DEATH (See Instructions and exainDles)
<br />it 014111Nh of Wend!- 4111aaas, InJwiet, or compllcatkms.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />dilation without showing the etiology. 00 NOT ABBREVIATE. Enter only one dose. on a :.lino. Add additional Tines R neoasss,y.
<br />MEDIATE CAUSE:
<br />Oratory failure
<br />ERLYIN9 Cl
<br />wy that Mite
<br />uIting'Id dsa
<br />DUE TQ, OR AS A CONSEQUENCE OF:
<br />b) human metapneumovirus
<br />TO, OR AS A CONSEQUENCE OF:
<br />A CONSEQUENCE OF:
<br />I'B ,PART 11.:.o:7.HER:SIGNIFICANT'CONDITIONS-Condltlons contributing to the death but notreeultlng in the underlying cause given In PAItT 1.
<br />multiple rnyellorria chronic kidney disease stage 4, dysphagia, aspiration,
<br />TSB
<br />42 days M deer
<br />s to year Ireton
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homttkle
<br />❑ Accident 0 Pending;lnwstgatlon
<br />❑ Suicide ❑ Could not be datermMed
<br />22b. TIME OF INJURY
<br />BE HOW INJURY OCCURRED
<br />i
<br />UMBER, APT.NO.
<br />Yr.) 23c. TIME OF DEATH
<br />02:48 AM
<br />r dtMk[! dudine,
<br />eaned at the dateand place
<br />bad dii 0thR>llvielsistittW
<br />Isaac J. Be,MD
<br />(signature and TRW
<br />TO THE DEATH?
<br />MY 0 UNKNOWN
<br />21.0. IF•TRANSPORTATION INJURY
<br />QDriverri0psrator
<br />..
<br />❑ Pasi sneer
<br />❑ Pedestrian
<br />❑ Other (*pacify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />21c. WAS All
<br />©YES
<br />24C..PRONOUNCED DEAD (Mo., Day, Yr.)
<br />t e 6asts of examination and Mveatigation,
<br />the lima, date and place and due to the cawe(s) atatet
<br />25a. HAS ORGAN OR:TISSUE DONATION BEENGONSIDERED?
<br />0 YES r"1 NG .'
<br />ExAND ADORE * OP. CERTIFIER (Type or Print
<br />tR'8MD, 729 North Outer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />EI I TiIRE 1
<br />25b. DATE FILED BY
<br />February 7, 2
<br />ive 14a. INFORMANT -NAME
<br />Margaret Kohler
<br />191. EMBALMER -SIGNATURE
<br />kDaniel D Naranlo
<br />
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