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<br />STATE OF NEBRASKA
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<br />WEISN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT. CERTIFIES THE DOCUMENT BELOW
<br />BEA rRLW':COPY 'OF`THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND . , HUMAN SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />•
<br />•
<br />DATE.Oi = s;$ ANC .
<br />Sf5/025'';:::.
<br />LINCOLN NEBRASKA
<br />I:DECEDENTS406f6E:(FIrs# Middle, Last, Suffix)
<br />1Marvtrl;>14alth'" Nietfetd
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grad i3.Jslal cl Nebraska
<br />'SOGIA SECU:RITYNUMi>ER
<br />8b. FACILITY -NAME (If not InstitutIon,give street and number)
<br />�t93".Ft. l<ear.Cls'i+::i3Dad
<br />OE. CIVr OR TOWN OF DEATH (Include Zip Code)
<br />Grand: Island > 68801
<br />9a. RESIDENCE -STATE
<br />,Nebraska
<br />9Ai STREET'AND NUMMSER'<'
<br />494 Et _Kea,rney,Ftbad
<br />9b. COUNTY,
<br />i
<br />Merrick
<br />202504583� ""t'
<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 />5a. AGE Last Birthday
<br />(Yrs )
<br />/ . 7.5::.
<br />10a. isiall'AL STATUS ATTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1:1 FA t (ER S NAME (Rttttt '` M
<br />R#Ittplp
<br />Ili, Last, Suffix)
<br />13. EVER IN U.S.'AFIMB© FORCES? Give dates of service If Yes.
<br />(Yes, No, or`Unk.) Yes 10/04/1965-02/17/1966
<br />15. METHOD .OF::DISPOSITION
<br />0 Burial ::.' 0 Donation:::
<br />}'Cremation"; ,j Entombment
<br />ment
<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 />'8a, P* ACF OF:.DEATH:.
<br />HOSPITAL ::❑ Inpatient
<br />0 ER/Outpatient
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE
<br />Septemt
<br />6. DATE•`i
<br />Aprllr26,'
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />Ied. COUNTY OF DEATH
<br />Merrick
<br />i
<br />De: APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Victoria Ann/ Cunningham
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lillian Dankert
<br />14a. INFORIANT-NAME
<br />Victoria Ann Nietfeld
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1Ta,•FIaNEi4AI I i7MEMAM'E_ANDMAILINGADDRESS (Street, City or Town, State)
<br />All FaiI Ft4 te(& He mee, 2929 S. Locust Street, Grand Island; Nebraska
<br />166. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />7
<br />CAUSE OF DEATH' (See instructions and examples)
<br />t
<br />IL PART). Enterthachekt of everns..disssees, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or vertlricularr1iDdItat)on without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on aline. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Colon Caner
<br />04TE:D USE
<br />(:srgondHaor
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Serrygrtiafly lift condaions, H b)
<br />am ,105dtnglenisteau4sSstsil:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter ttaf:6460aLyINg CAUSE 9 -
<br />Idiseaes orinlurythat initiated
<br />the events resohing In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST .._. d)
<br />18. PART 11:43THER:EItsfiji:
<br />2d :fF FEMA.
<br />No#prgnaint.:valftdn:t at
<br />y Frsgnuif.at of ilga h
<br />Not Pfegnant, but pnpnrrd within 42 chive of death
<br />Not prsgnam, but pregnant 43 days to 1 year before death
<br />�?'� 1JtArnov+rpH pCey)nant till t)sn the past seer
<br />ANT CONDITIONS -Conditions contributing to the death but not
<br />14 DATE TE Cip)O. (RY (M©..Day, Yr)
<br />22d. INJURY AT WORK?
<br />ulting: in the
<br />21a. MANNER OF:DEATH.
<br />Natural ❑ Hamicdda
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />i
<br />22b. TIME OF INJURY
<br />erlying cause given in PART 1.
<br />21b;;:(F:TRANSPORTATION INJURY
<br />rdrivsripperator
<br />passenger
<br />❑ Pedestrian
<br />r
<br />0 Other (Specify)
<br />22c. PLAGE.OF INJURY -At horn
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY:: S3'REST d, NUMBER; APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 7, 2019
<br />:234,. DATE;SIQNED.(Mo., Day, Yr.)
<br />SQpE mb r'9�::2019
<br />2
<br />23e. TIME OF DEATH
<br />12:52 AM
<br />(te::)last:afiilry:knowledge, death occurred at the time, date and place
<br />ldB4 to,itb:suse(s) stated. (Signature and me)
<br />n Ramaekers, MD
<br />I'fi1ACC6:USi:CON:TRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />7. NAME. ;'i')UA( i) All?DRESS
<br />Ryan Ftarllaekers, MD, 2
<br />2Qa RE iISTRAR'S St NATURE
<br />IER (Type or Print
<br />Faidley Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORIIAN
<br />❑ YES
<br />7
<br />14b.
<br />. 'Sp©u
<br />16c. DAT
<br />September;)
<br />ti
<br />t9. WAS
<br />OR:GORO`,
<br />❑ YES.
<br />21c. WAS AN AUTOPSY:
<br />❑ -PES
<br />21d. WERE AUT
<br />TO COMPLE
<br />❑ YEs.
<br />farm street, factory, office building, conatruction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. 'ma O D
<br />24d. TIME PRONQ#+1NCED
<br />24a.0n the.basie of examination and/or investigation, I Opiniion die*
<br />the tlms; date and place and due to the cause(*) stated (5ipnatyre a
<br />:TISSUE DONATIQN :BEEN CONSIDERED?
<br />NO :::.. .........
<br />26b. WAS CONSENT iRAN ♦ ' ;..:;;
<br />Not Applicable if 26a is NO :YES
<br />28b. DATE FILED BY REGI
<br />September 16, 20-19
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