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<br />STATE _-. OF NEBRASKA _,..
<br />tv,Wlxrvo..,-,ar€rt564y9"l##txt5oa,. ,.:.zoar "" mszamassriemogoymm,ce ...
<br />WHEN<THIS; COPY` Al+i!I.',"IESS; THE RAISED SEAL OF STATE OF NEBRASKA, :IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE itTRUE,COPY0 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 />DATE OF ISSUANCE::
<br />3l2012025
<br />UNCOLN, NEBRASKA
<br />2025059954.36t4tA 6#4im.
<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 />14iECEiENVS..N: ME (First..":. Middle, Last, Suffix)
<br />ItttrindaKaIr':' Denman
<br />4:'CITY AND'STATE..•OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand :Island;:Nebraska
<br />?.:SOCIAL SECURt'rY.NUNEER
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />66
<br />8b FACIUTY•NAME (If not Institution, give street and number)
<br />.407 Ltlly:Street;..
<br />CITY CR TOWN OP DEATItanclude Zip Code)
<br />Wood `Rtv r 688$3 '':>
<br />lice R);SIDENCE-STATE
<br />Nebraska
<br />9dSTREETANA NUMBER'
<br />407 Lilly Street
<br />9b. COUNTY
<br />Hall
<br />itla. MARITAL STATUS AT.tIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated El Widowed ❑ Divorced 0 Unknown
<br />11.FATHER'SNAME;(Flrst; > ,Middle, Last, Suffix)
<br />;:::Norman
<br />13. EVER IN U.S. ARMED ace Give dates of service if Yes.
<br />(Yes, No, or unit) NO
<br />METH
<br />OD
<br />E :..R OF D1SPOS)TION
<br />Buttal (.Donation
<br />".'0 CYem.tlori O;Enteitnhri eftt
<br />0 Removal ❑other (Specify)
<br />db. UNDER 1 YEAR
<br />2. iEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />ES. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient: OTHER 0 Nursing Homs/LTC-
<br />DAYS
<br />HOURS
<br />MINS.
<br />❑ ER/Outpatlent
<br />0DOA
<br />9c. CITY OR TOWN
<br />Wood River -
<br />® Decedent's Home,
<br />0 Other(Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />De. APT. NO,
<br />9f, ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wits, give maiden n
<br />Kimball Charles Denman
<br />12: MOTHER'S -NAME (First, Middle, Maiden Surname
<br />14a. INFORMANT -NAME
<br />Bobbi Perlin
<br />18a. EMBALMER -SIGNATURE
<br />Baylee J McAtee
<br />Pearl ;: M : Reed
<br />183i. LICENSE NO.
<br />:1604
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Wood River Cemetery Wood River
<br />1TaFUNERA:k.:HQME NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br />Arite(Furierat Home, 1123 W, 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />I
<br />a- PART L Enter the cheat Mamma- -diseases, injuries, or complicadons4hat directly caused the death. DO NOT enter Uniting.'
<br />l .ins such as cantles arrest,
<br />respkatory arrestor ventricular 8bdlatlon without showing the stlolopy. DO NOT ABBREVIATE. Enter only. one cause on a N.ns. Add additional Iims 8 necessary.
<br />IMMEDIATE CAUSEi1
<br />IMMEDlATECA) 1$ (Pawl 13)Lungcancer
<br />}Alice.. or Condition restlaing: •
<br />DUE TO, OWAS A. CONSEQUENCE OF:
<br />Ssquendally list conditions, w b)
<br />4n4teadin.9,*Ott+:. attar lietelt
<br />„Nadir the'ut RLYINo4A1.18E.. ..
<br />'S (disease or irdury that inhiat.d
<br />the events restating in death)
<br />LA8T
<br />we TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />;d)
<br />18. PART>U,.C...THER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not:.reaulting in the, roderlying cause given In PART I,Gtlrtxlic obstructive pullitonery disease
<br />20.11 ;FEMAEE':; . :.
<br />;;Not pngnsntWUdn:pasl yur
<br />} Pros' nant at piirt_:pf dsaUi'
<br />• Not pn4fi rent, bur pregnantidihin 42 days mown
<br />© Not pregnant, but pregnant 41 days to 1 year before death
<br />r' 0knowrj.f pryrg uM:widdliiha.pasW
<br />t ar
<br />QF.)NJURY3(M 4 pool,),
<br />22d. INJURY AT WORK?
<br />ayes Ho
<br />21a. MANNER OF DEATH'
<br />RI Natural 0 Homkhp
<br />Accident J,P.ndII5 hw..tigetion '..:
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b: IF,.TRANSPORTATION INJURY
<br />0 Driver/©perMor
<br />Paasrr:ig.r
<br />0�a P.dn
<br />0 Other (Specify)
<br />22c. PLACE:OF:INJURY-At hOrna :Tenn,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />T1OCi OF INJURY ,: $7iieET i NUMBER, APT.NO. CITY/TOVUN ..
<br />23a DATE QF DEATH (Ma, Day, Yr.)
<br />March +4, 2025
<br />23b 1ATE.SIGNED tM0., Day, Yr.) 23c. TIME OF DEATH
<br />Mar . 25:<:: 03:13 PM
<br />ixd. Toad. adat orrtiy_:kniasidga, death occurred at the time, date and place
<br />:SO drill#VW c+ri+*(*) stated. (signature and Title)
<br />Chad Vieth, MD
<br />25 03226
<br />3. DATE OF DE.ATtii:(M.. DaY,..Yr-/
<br />March 4, 20
<br />6, DATE OF BIRTH (Mo., Day, Yi):
<br />April
<br />f4C plcaFticfl..,
<br />14b. RELATIONSHIP
<br />Daughter,
<br />1
<br />6c DATE (Moe, Day,'Th),.,
<br />,Ch
<br />Nebrask
<br />1Tb.:Sfj1
<br />688.
<br />onset to
<br />le:Arks M
<br />OR cos
<br />/ ®YES
<br />21 c. WAS AN AUTOPSY PERFOR
<br />O Yea
<br />21d. WERE AUTOPSY ROC**AVI
<br />TO COMP ETEDA1 OF
<br />❑ YES. CI NG':::
<br />(treat, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />246. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEA
<br />24d. TIME
<br />4.. on.lhi: bca*. ef.xamimdon and/or InvxSgatlon, In my opinion
<br />die t*h*i dip and place and due to the caved') stated. (8ONSOra
<br />6 pie TOBACCO USE CONTRIBUTE TO THE DEATH? N:: TION
<br />YES :lQ NO :::0 PROBABLY 0 UNKNOWN
<br />37= N4ME.r;T(iE;BA It AD SS OF CERTIFIER (Type or Print
<br />Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />Cbad Vieth;
<br />26a. HAS ORGA
<br />❑ YES
<br />OR pesUE:DQNA
<br />NO
<br />BEEN::CONSIDERED?
<br />26b. WAS CONSEN
<br />Not Applloabie If 26a is 1
<br />28b. DATE FILED BY
<br />March 10, 2025
<br />
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