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STATE OF NEBRASKA <br />s5+,7.�ti;;6M.S.... ;.:asi/1lI"i'411w'�Q:> .•. n4t1555.A. Ncr».:<72.YiP11d.Fa>`...:c<744/5monos•>',>.: saeN,UdlD.,N'ca...sa44'I'I'I`{i'IPP! <br />RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO <br />THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND <br />'TAt* RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />202504376 <br />SAR.AH BOHNENKAMI' <br />ASSISTANT STATip REGISTI <br />DEPARTMENT OF HEALT <br />AND HtMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />/ CERTIFICATE OF DEATH <br />st, Suffix) <br />ATE'<7R llRl tQRY.'OR FOREIGN COUNTRY OF BIRTH <br />Code) <br />and number) <br />. COUNTY <br />Hall <br />Married 0 Never Married <br />❑ Divorced ❑ Unknowtt <br />s of service If Yes. <br />5a, AGE - Last Birthday <br />(Yrs.) <br />5b. UNDER 1 YEAR <br />8e. PLACE OF DEATH <br />HOSPITAL ❑ lnpatiant <br />❑ ER/Outpatient <br />❑ DOA <br />9c. CITY OR TOWN <br />Grand Island <br />2. SEX <br />Male <br />5c. UNDER 1 DAY <br />HOURS <br />OTHER ❑ Nursing Homs1LTC, <br />❑ Decedent's hont. <br />Other (Spsciil')A$ J <br />18d. COUNTY OFDEATH <br />Hall <br />is, APT. NO. <br />9f. ZIP CODE <br />68803 <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give <br />Amy Wiegert <br />14a. INFORMANT -NAME <br />Cheryl Larsen <br />EMBALMER -SIGNATURE <br />Not Embalmed <br />. CEMETERY, CREMATORY OR OTHER LOCATION <br />ventral Nebraska Cremation Services <br />MAt#.1NG ADDRESS (Street, City or Town, Stan) <br />$ IN 2nd, Grand Island, Nebraska <br />, NOTHER'S-NAMS (First, Middle, Malden Su <br />$el111a Helena Peterson <br />b. LICENSE NO. <br />CITY / TOWN <br />Gibbon <br />CAUSE OF DEATH tSee instk,li ctions and examDlee) <br />igis�aaii, btlitrtes, or compliationsah►t-directly caused the death. DO NOT enter terminal events such as cardiac ern , <br />Wiliiatl�n whhotd showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes If necessary. <br />MEDUi,TE CAUSE: <br />igsttlhlgeal cancer <br />AS A CONSEQUENCE OF: <br />A CONSEQUENCE OF: <br />E TO, OR AS A CONSEQUENCE OF: <br />T'tt; 2025; <br />el Eli' 5 <br />NS-Condidons contributing to the d <br />na'nutrition <br />but not resulting (n the 4n <br />21a. MANNER OF DEATH <br />RI Natural 0 Homlcldi <br />❑ Accident ❑ Pending Inv stig(ition <br />❑ Suicide ❑ Could not be determined <br />TIME OF INJIURY <br />22c. PLACE dF INJURY -At ho <br />BE HOW INJURY OCCURRED <br />UMBER, APT.NO. <br />CITY/TOWN <br />23c. TIME OF DEATH <br />08:32 PM <br />curved Alm time, date and place <br />Wre and TRIO- - <br />eriying cause given in PART 1. <br />Ib. IFTRANSPORTATION INJURY <br />0 DrNer/Operator <br />0 Paaaartger <br />0 Pedestrian <br />❑ Other (Specify) <br />21c. WAS AN <br />©YES <br />frost, factory, office building, co <br />STATE <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. 11 <br />toe. On the basis of examination and/or Invesdge ion, in my ap <br />the time, dab and place and due to the cause(*) ayttedrp <br />1D THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />Y J, UNKNOWN <br />T1FtER (Typo or Print <br />CI#400, Box 9802, Grand Island, Nebraska, 68803 <br />❑ YES 121 NO <br />26b. WAS CC <br />Not Applicable <br />26b. DATE FILED BY REfi <br />March 24, 2025 <br />