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OP <br />VICES <br />STATE OF NEBRASKA <br />.iZT,,,h4G9Y1V 000?!,' <br />0 ! GE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW <br />I11IAL RECORD ON FILE WITH THE NEBRASKA . DEPARTMENT OF HEALTH AND <br />REC RDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />202503974 <br />jtj 6iteLeiI4 <br />SARAH BOHNENRAMP <br />ASSISTANT STATE REGISTRAI <br />DEPARTMENT OF HEALTH <br />AND HUMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICA7. 9F QVATH <br />Last, Suffix) <br />EION COUNTRY OF BIRTH <br />va strest and number) <br />e ZIp Code) <br />9b. COUNTY <br />Hall <br />H Married 0 Never Married <br />d 0 Divorced 0 Unknown <br />Last, Suffix) <br />Sb. UNDER 1 YEAR <br />8a. PLACE OF DEATH <br />HOSPITAL 0 Inpatient <br />❑ ER/Outpatient <br />❑ DOA <br />9c. CITY OR TOWN <br />Dannebrog <br />2. SEX <br />Male <br />Sc. UNDER 1 DAY <br />HOURS <br />OTHER 0 Nursing Hornei'LTC <br />® Decedent's Horne <br />8d. COUNTY OF DEATH <br />Hall <br />APT. NO. <br />9f. ZIP CODE <br />68831 <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give <br />Diane Heminger <br />es of service if Yes. 14a. INFORMANT -NAME <br />Diane Greenough <br />a, EMBALMER -SIGNATURE <br />Not Embalmed <br />1.; MOTHER'S -NAME (First, Middle, Malden Su <br />Ellen Sand <br />EM)TERY, CREMATORY OR OTHER LOCATION CITY / TOWN <br />stlawn Memorial Park Crematory Grand Island <br />ADDRESS (Street, City or Town, State) <br />ral Home, 411 0 Street, PO Bdx 112, St. Paul, Nebraska <br />CAUSE OF DEATH (See instructions and examples) <br />es, or complicationsehat dinedy caused the death. DO NOT enter tannins) events such as cardiac arrest„ <br />ut showing the etiology. DO NOT ABBREVIATE. Enter only one -cause on sling. Add additional lines If necessary. <br />USE: <br />TO, OR AS A CONSEQUENCE OF: <br />ASA CONSEQUENCE OF: <br />A CONSEQUENCE OF: <br />TJONS GonditIons contributing to the death but not <br />re gnsntvAttt!rl t2daysoldeath <br />tpN#Ihl`4'gays tot year heron death <br />ttwl�tx'ttia aria tissr <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident 0 Pending Investigation <br />0 Suicide ❑ Could not be determined <br />TIME OF INJURY <br />22c. PLACE OF INJURY -A <br />RIBS HOW INJURY OCCURRED <br />BER, APT.NO. CITY/TOWN <br />23c, TIME OF DEATH <br />05:26 PM <br />conid at the time, date and place <br />tun and Title) <br />lb. (PTRANSPORTATION INJURY <br />0 Driver/Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21d. WERE AWl <br />TO COMPt. <br />© YEO <br />farm, street, factory, office building, co <br />STATE <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />249. PRONOUNCED DEAD (Mo., Day, Yr <br />24#, iln the hinds of examination and/or Investigation, In my <br />the time, data and place and due to the cauee(.) stated <br />rI,rp,THE DEATH? 26a. HAS ORGAN OR SS iE DONA't#C N BEEN CONSIDERED? <br />ABLY tZ1 UNKNOWN I ❑ YES El NO <br />IS QEkTIFIER (Type or Print <br />) Faidley #400, Box 9802, Grand Island, Nebraska, 68803 <br />26b. WAS CONSi 1 <br />Not Applicable If 26a I <br />28b. DATE FILED BY !( <br />February 25; 21 <br />