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<br />Miami, Injuries, or complications. hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />a, q(;uRtRliiularrbttillaaon without showing the etiology DO NOT AQEREVIATE. Roo only:ona cease on. Cline. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />•
<br />.a)Pulmonary Fibrosis
<br />TO, OR AS A CONSEQUENCE OF:
<br />DUE TQ, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />iNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />STATE OF N E'Ki emB..R,srtA+t
<br />$KA
<br />.:rta�'.anmotM;tht 9
<br />tANrt*>`•ctzrt4444wgxsat��!�!�ey %lllrllhi111y�4a5
<br />,���,1,.=E, �u11111�11.,:::
<br />1 coPv cm1�'.IES THE RAISED SEAL OF STATE OF NEBRASKA ITt ERTIFIES THE DOCUMENT BELOW TO
<br />4 TRUE COPY ?F ME ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />AN SERVICES,, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Are OFISSUANCE
<br />I0/24I202$
<br />04N..NEBNASKA
<br />202506357
<br />06414tiliket
<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 9F DEPTH
<br />Middle, Last, Suffix)
<br />CITY AND TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />h
<br />7, S# (ALSEGURlTY:HUM ER
<br />84742-6691
<br />LITY»NAM); (IF not Institution, give street and number)
<br />9500 SouttiAlda"Rd s..
<br />9V0ttCC River 688
<br />L=1#E$1DENCEaTATE
<br />Nebrake::
<br />95i}t3;South: Aida;Rd
<br />(include Zip Code)
<br />9b.000NTY
<br />Hall
<br />RITAL'STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />Rled, bt IIIIPPRlGd ❑ Widowed ❑ Divorced ❑ Unknown
<br />ATHSR S,NAME (Irst : Middle, Last, Suffix)
<br />�ricsCi;r .:?Fol#1#Irtitn
<br />VER IN U.S. ARMED FORCES?
<br />,: (Y..PIP. 'PT Vnk4 Yes
<br />E114Gn 0 :eiSP Il.t: er4
<br />F ( Et tombMint
<br />pacify)
<br />5a. AGE - Last Birthday
<br />(Yre.)
<br />80
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.,
<br />DAYS
<br />flit PLACE QF..DEATH
<br />HOSPITAL "❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ .. .. .: D3 A.
<br />9c. CITY OR TOWN
<br />Wood River:.
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT ..(.o.,,f
<br />QGtQr'.�12
<br />e. DATE Of BIRTH (Mtl„ Day. Yr,)
<br />April,81
<br />OTHER ❑ Nursing Home/LTC
<br />Decedent's Home
<br />❑ Other (Specify) .
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, gl
<br />: , :Betty .:Dunbar;:::::
<br />14e. INFORMANT -NAME
<br />Betty . Fogleman::..
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Caleb J Alcorta
<br />12. MOTHER'S -NAME (First, Middle, Maiden SurltlltM)
<br />Holma Sapaugh
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />FIME, NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />s;Funera4 Ronne, 2929 S. Locust Street, Grand Island; Nebraska
<br />10. LICENSE NO.
<br />:1607
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examoleal
<br />Hitcat041111iul
<br />INDERL'
<br />or injury that
<br />u
<br />pAI T2Is`Q .
<br />fd'1ymllhohisttO`cytosis, lung cancer, chronic obstructive pulmonary disease
<br />Not' prrp11111%14?thili M
<br />Pr.an:ar t aithfla of gpittt
<br />et Pregnant, but r/Mgnsntwithin 42 days of death
<br />iSR p!�.gria !ks::l�;i!I'W�Ip11#!rr }tJ days to 1 year Mrore.,dsath
<br />yn+yl:w!Hflfi the Past year
<br />Mv«::bey; Yr )
<br />K?
<br />RI
<br />GR.
<br />-ATE OF',DEATH (Mo., Day, Yr.)
<br />Cctober 9, 2Q25 .
<br />21a. MANNER OF DEATH .;
<br />Natural mammas
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21ti' IF TRANSPORTATION INJURY
<br />.Dr/et/Operator
<br />•Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />rre
<br />14b: REIATION$(jIPTODECRDRNT
<br />Spouse ;:..'. ....._ .....
<br />160. DATE (
<br />October 2(
<br />16. WAS ME
<br />ort'CQRQ
<br />® YES'
<br />21d. WERE A
<br />TO COMP
<br />0 YES
<br />22c. PLACE OF IN iURY:At home, firm, street, factory, office building, cons!
<br />HOW INJURY OCCURRED
<br />NUMBER, APT.NO.
<br />bl EfkTS. (fl NED . M,o;, Day Yr.)
<br />•
<br />'o Sto butf;t 0":kt oMed0., death occurred at the time, date and place
<br />and.`tiuir to tin cauae(t) atI d. (Signature and Tito)
<br />shad Vieth, MR
<br />CITY/TOWN
<br />1�?
<br />TtTt>e 1tpO' AtNlREi
<br />Vietttw tu1[?, , 211l
<br />4TRAR'S.:EIMNA F
<br />23c. TIME OF DEATH
<br />08:16 AM
<br />UTE'rO THE DEATH?
<br />IABLY is UNKNOWN
<br />F CERTI IER (Type or Print
<br />Feeley #400, Box 9802, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />. ARONO JNCEO DEAD (Mo., Day, Yr.)
<br />lei. TR*OFpia
<br />'
<br />Zip. On the.:basis of examination and/or invsetigauan, in MY
<br />the time, date and place and due to the cause($ ttstad=(
<br />'26a.HAS ORGANOR TISSUE DONATIONSEEN:CONSIDERED?
<br />❑ YES 1410
<br />26b, WAS CONSENT
<br />Not Applicable N 26a Is
<br />26b. DATE FILED SY
<br />October 21, 2
<br />
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