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<br />STATE OF NEBRASKA
<br />COPY Ai R THE 12AISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A_ tl»"C+C FYt F ThE OIV#3 A1AL, RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />ORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202505302
<br />keit
<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 Q>F' DEATH
<br />2, SEX
<br />Male
<br />EIGN COUNTRY OF BIRTH
<br />ActUTYsAM6 Npalbet u*(on,'gWesheetandnumber)
<br />11;1~e t CERitaE1'.AYeraue
<br />tI Dt YC1tis)N.t7 tkEA ITt={tndtudeZip Code
<br />°Nebra
<br />9b, COUNTY
<br />Hall
<br />EiEATH g] Married ❑ Never Married
<br />dow@lt ❑ Divorce' 0 Unknown
<br />•E :S-NAA11 (f itsti'::' ►�Ittdte; Last,/ Suffix)
<br />EV C(IV U:S; ikiRMED;PO
<br />lea, Nu;�oTilrt9si IUD � '.
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />a. P(.ACE OF DEATH
<br />HOSPITAL ❑ inpatient OTHER ❑ Nursing Hom<C
<br />❑ ER/Outpatient ® Decedent's Honk,
<br />Q<DOA 0 Other (SecIfy);
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c: CITY OR TOWN
<br />Grand Island
<br />Ire, APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give prat
<br />Myra Cline
<br />12. MOTHER'S -(SAME (First, Middle, Malden Sut1M
<br />Evelyn House
<br />14a. INFORMANT -NAME
<br />Myra Oshlo
<br />FUNERAL DIRECTOR SIGNATURE
<br />regory L. Nabity
<br />b. LICENSE NO.
<br />d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Mid America First Call, Inc Omaha
<br />NQNI% JE MAIUNG ADDRESS (Street, City or Town, State)
<br />Desk GrrltoKlSodety, 911 N Linden St, PO Box 127, Wahoo, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />IwHes, or complicationsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />Ihout showing the etiology. DO NOT ABBREVIATE, Enter only one came, on* Mg. Add additional lines if necessary.
<br />CAUSE:
<br />Idt-Jakob disease
<br />TO, OR AS A CONSEQUENCE OF:
<br />OR A$ A CONSEQUENCE OF:
<br />iti.(t 4t7 ni ;lrril IF1ANT#NDiT(CtNs-Conditions contributing to the death but not resulting in titer utidsrlying ckiuse given in PART 1.
<br />AT.vyORK?
<br />4; days of death
<br />t tO l year before death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 suicide ❑ Could not be determined
<br />b. TIME OF INJURY
<br />21b. IF TRANSPORTA11ON INJURY
<br />❑ DtiveriOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN
<br />❑YES
<br />21d. WEREAi
<br />TO COMP
<br />❑ YQS
<br />22c. PLACE OF INJURY•At home, farm, street, factory, office building, cons
<br />E HOW INJURY OCCURRED
<br />BER, APT.NO. / CITY/TOWN STATE
<br />D15i'#11;, Days Yr.)
<br />Ira Yr,)
<br />23c. TIME OF DEATH
<br />02:1 r'PM
<br />ath occurred at the time, date and place
<br />1;I(Mature and TRW)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />241.0n the Rams of examination and/or investigation, in my estipl
<br />the time, date and place and due to the camels) stated. (aql
<br />lil:t0 iti..f:p t (2t)kTE TO rHE DEATH? 26a. HAS ORGAN OR TISSU Al ON BEEN CONSIDERED?
<br />:PMRQBABLY' ❑ UNKNOWN ❑ YES i7 NO
<br />iEEI JtiIER (Type or Print
<br />Ave, Grand Island, Nebraska, 68803
<br />26b. WAS CONSEh
<br />Not Applicable if 28a
<br />28b. DATE FIL
<br />September 4, 202
<br />
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