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<br />STATE OF EBRASKA
<br />s:;t t7trrPd,MtSa.s aed?i07,1711111
<br />-"ettemir.e.M;;;;ITIPV� SSI. �SuDFRac.•:
<br />ENT .5 GOPY:CARRJLS THE RAISED SEAL OF STATE OFN BRA K4 n`:i ,FI 1'1FIES THE DOCUMENT BELOW T1
<br />SEA' TRUE:1COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA :DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE`QF' SSI!llAif E
<br />•
<br />'8/4/2025::;'
<br />LINCOLN, NEBRASKA
<br />202513671 ASSISTANT STATE REG
<br />".; DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DECEDENrs44AME :(fr tat Middle, Last, Sufi )
<br />Shaccn ,:illlbt'?k}fi
<br />4, CITY AND STATE OJ TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Frg(itfirt, Nebraska::::
<br />7 SOCIAL:SECURETYNUMBER
<br />505=544460;'
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />" Gran'd 1a00:13ick.:ogt Cottage L.L.C.
<br />Sc. oily OR: fQ]lYN OF,DEATH (Include Zip Code)
<br />a' Grantl't3lattt 681
<br />9a.'RESIDENCE-STATE
<br />Nebraska< :>:
<br />id. 57REE?r: tNC NUMt ER ;' .
<br />23t t..1W': Custer Ave:'
<br />Sb.000NTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never -Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />ti:1i FATHERS NAME :(First; '..;:
<br />Emmett Rasmussen •
<br />13. EVER IN U.S: ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />:15 METHOR;DE':AISPOst.ON
<br />oi-t Scandal::''; Dsanstioel
<br />Cremation(0 Entombment
<br />❑ Removal ❑Other (Specify)
<br />addle, Last, Suffix)
<br />Give dates of service if Yes.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a.f. AGEOF:PEA'fh':
<br />HOSPITAL. ;Inl atlent
<br />CIER/Outpatient
<br />0 DOA'
<br />9c. CITY OR TOWN
<br />Grand:island
<br />HOURS
<br />MINS,
<br />OTHER 0 Nursing Home/LTC'
<br />ElDecedent's Home
<br />® Other (SPecifylASSI$TerfP (Itl +
<br />3. DATE OF DEATH;{
<br />July.25, 202Eii
<br />6. DATE OF BIRTH (Mo.,
<br />May 15,.194E::::
<br />H*pice F
<br />k Yk}
<br />led. COUNTY OF DEATH
<br />Hall
<br />Tat. APT. NO.
<br />Ts. NAME OF SPOUSE (First, Middle, Last,
<br />12, N1E THER'S-NAME (First,
<br />Billie ' :Brookes
<br />14a. INFORMANT -NAME
<br />Christi Rademacher
<br />Tea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />FUNERAL HONE''NAME:AND MAILING ADDRESS (Street, City or Town,:State): .... .
<br />Alt: Faiths Funeral Home, 2929 S. Locust Street, Grand Island;, Nebraska
<br />1Bb: LICENSE NO.
<br />Sf. ZIP CODE
<br />68803
<br />Suffix) if wife, give maiden name
<br />Middle, Maiden Surname
<br />CITY ! TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />t
<br />14. PART t. Enter, the chitin siiseases, injuries, or complications4het directly caused the death. DO NOT enter terminal events such as cerdlso arrest,
<br />respiratory arrest, or vernpculsr fibrillation without showing the etiology. DO NOT ASSIlEVIATE4nter only one pose on aline. Add additional lines if necessary.
<br />a)Cerebral infarction
<br />MEDIATE CAUSE (F ...:..;:
<br />Olsten ..Q condition reetbtin j.
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />:BWwM(lint ; b) "
<br />COMdion;s,,if
<br />IMMEDIATE CAUSE:
<br />., :::3py, 1U41fl5 to tht.,.hrnrae t lead
<br />OR AS A CONSEQUENCE OF:
<br />Enter tea disCORLYiNG CAcisE 'c)
<br />45 ldiseaas or injury that initiated
<br />the events suldng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />16. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the:;death btit:rlot;t
<br />Atrial fibrillation, chronic obstructive pulmonary disease, hypertension
<br />'" eneM Wtttiin plat feet
<br />1!tagnlitltat Umr�oFdwih:'f �
<br />NO2 pre. gnent bld,preandnt within 42 days of death
<br />Not pregnant, but ptSnam 43 days to year before death
<br />Unknown d pregnenE:wi*Itlglhe past year
<br />22a. DATE;OF INJURY>(Mo ;. pay, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES ONO
<br />of
<br />AS 2i
<br />tV "
<br />3
<br />21a. MANNER OF DEATH
<br />Natural ❑ Holnllt4e
<br />❑ Accident ❑ Pethig p invaili
<br />0 suicide ❑ Could not be determined
<br />1
<br />iulting ihtie underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />22c. PLAG
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21b:W TRANSPORTATION INJURY
<br />[1.0rlyeqOperator
<br />(rOpttiger
<br />0 Pedestrian
<br />❑ Other (specify)
<br />14b, RELA
<br />Daughter N`
<br />_16c. DATE (Mir;;:Day, Yr
<br />July,29; 202 ;:
<br />ittATE
<br />Nebraska
<br />170 oo is
<br />88801'
<br />A
<br />APPROXIMA
<br />*neat tc:;ti
<br />VVetektiP.i:
<br />111: WAS ME
<br />OR CORON
<br />21c. WAAUTOPSYP
<br />❑ YES
<br />21d. WERE AUTQPSY FNfPIN6S AVA
<br />TO COMPLETE CAUSE Of
<br />p YES .0 'ND•
<br />INAIRY,rA:t; hctnt, fern), etrest, factory, office building, cons
<br />L{ CATION 012INJURY ;:-STREET & NUMBER, APT.NO. CITYIT©WN': STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July ?5, 2025
<br />39, DATE WOOD (MO., Day, Yr.) 23c. TIME OF DEATH
<br />#lyt>202§ 07:27 PM
<br />31i iq. To;al p:luiet.M iffy; knowledge, death occurred at the time, data and place
<br />widths' tatlai Puss(*) silted. (Signature and Title)
<br />Chad Vieth, MD
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />Mc. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONO
<br />of examination and/or investigation, In my-eDingn
<br />t e tiro, data and place and due to the cause(s) stated. Ithipebm;
<br />D(D TOpi1C f ..USEUO(TRi8UTeTO THE DE4 H?
<br />❑`PROBABLY ig} UNKNOWN ❑YES ``
<br />7. rf AtE :'TITLE..AttAbERESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 6880
<br />26a. HAS ORGAN rJl':
<br />'DON,
<br />i10
<br />E£N;:CONSIDERED?
<br />26b. WAS CONS
<br />Not Applicable If 26a
<br />28b. DATE FILED BY REGISTR
<br />July 31, 2025
<br />
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