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STATE OF NEBRASKA____
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<br />YI 'COPY A RI S TtiE,RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />*E?Pl! i» rth ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />RViCES, ViTAt, RaC:RDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />SOCIAL SECURITY No
<br />O, .4O '1
<br />202505550
<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 QF DEATH
<br />die, Lest, Suffix)
<br />snails=A(taiirstid ci a1Center
<br />$IDENCE4TA
<br />braaka
<br />.EETANQ
<br />$`Lariat
<br />OREIS9N COUNTRY OF BIRTH
<br />9b.000NTY
<br />Hall
<br />fiA StA riiSA1 T!SiE QF DEATH ® Married 0 Never Married
<br />led,bdtseparftfd--: ❑Widowed ❑ Divorced 0 Unknown
<br />Last, Suffix)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />6b. UNDER 1 YEAR
<br />$a. PLACE OF DEATH
<br />HOSPITAL R3 Inpatient
<br />p ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />3. DA
<br />Au
<br />6. DATE OF1IitRiti1Mo, Osy,:Y
<br />OTHER 0 Nursing Home/I.TC
<br />0 Decedent's
<br />Horne
<br />0 Other ($P+rFIfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e, APT. NO.
<br />91'. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maldun n
<br />Geraldine Wiegert
<br />t2. MOTHER'S -NAME (First, Middle, Maiden
<br />Theodora Onken
<br />14a.INFORMANT-NAME- .
<br />Geraldine Hoagland
<br />a. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Si lit1 ftOME Nt1 N ''AND MAILING ADDRESS (Street, City or Town, State)
<br />itl~is:'ltsll;lSie3;-2 2 Locust Street, Grand Island, Nebraska
<br />lab. LICENSE NO.
<br />1439
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE QF DEATH (See instructions and examples) '\
<br />fsugnjono., or compiicetionsihat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />plrjytory' street ar vepptrllfr fit+ddstton without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on; line. Add additional lines If necessary.
<br />.';IMMEDiATE CAUSE:
<br />)A1t¢0Ai 1e irai ":;: :>alHepatic cirrhosis ' On
<br />Fiat r ciistitkrn. iuiti
<br />tab. RELA
<br />Spous
<br />D, OR AS A CONSEQUENCE OF:
<br />, OR AS A CONSEQUENCE OF:
<br />D, OR AS A CONSEQUENCE OF:
<br />'HER:$ taFIQANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART i.
<br />.dhi4 ic'kiditey disease
<br />I MA 4 ?. ,`; >; ; :.:<'::';:';: '. 2 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUT' ;
<br />NOC . 9 Natural ❑ Homdid0 Drlver(Operator
<br />t
<br />❑ YEs ,
<br />...
<br />0 Accident ❑ Pending Investigation 0 Pasatnger
<br />Nbtpypnatft )it pts5nanf withlrt4t days Of death 0"Pedeatrian 21d. WEREAU'rOlr$'
<br />❑ Suicide 0 Could not be determined
<br />tTO COMPLETE NsR gnpnsrd,Aut pnrgnpnK,}t!ya ot year its fore death 0Other(Specify)
<br />Ui*t*nviti iffxew ant yliiiln Nib Pas) year 0 YES
<br />DATA ilF IN p > M ;,:qay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At horn,,farm, street, factory, office building, construc
<br />((1RV ATMIf:Rti7 ' 22e, tESCRI$E HOW INJURY OCCU1RED
<br />'tC +4TiO 1 OF It lU Y -.s REST #NUMBER, APT.NIQ. CITY/TOWN STATE
<br />Fie DAtE OF DEATH(Ma, Day, Yr.) / 24a. DATE SIGNED (Mo., Day, Yr.) 24b TI
<br />' E#8t 2t 5 E' 1
<br />.,ib>:QA riwlt,1i ram, Day, Yr,) TIME Q DEATH 23c. F cI
<br />240. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. Tf
<br />g
<br />7 tit: TQ iryrl ilu. QFiiij(,: roiiNaSliit, death occurred et the time, date and place
<br />d-tifilk:tothiOlii cis) sttlbd, flyignstum and Title) .1
<br />Jennifer`Kinq, MD _ ii
<br />24e, 0n SW heels Of examination andfor Investigation, in my optplea dal
<br />the time, date and place and due to the cause(s) staled. (Slgobture
<br />rt'il CCau HE DEATH? 26a. HAS ORGAN OR TISSUE DONATI
<br />YES;::::'• '.:Nei•, PROBABLY ❑ UNKNOWN 0-YES idJ NO
<br />sr 1T'fl' A ,0 AK,l L$> OF CFiiTIMER (Type or Print
<br />Kink; Mgkz01 Broadwell Ave, Grand Island, Nebraska, 68803
<br />N CONSIDERED?
<br />26b. WAS CQNSENT 4i
<br />Not Applicable H 26s Is f
<br />28b. DATE FILED 13Y REOI5TI «kNi,.iM0.. Did; Y
<br />September 2, 2025
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