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EN.,.1 .. ,t'�r":':t Jr test, Suffix)
<br />STATE OF NEBRASKA
<br />4.4�.ddFro>> aotd461'19;ffflttDFS;.. .v8.�,9Y11,5.>=-�:
<br />COPY RR s r l RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />I ` RUE P% r QRt tNAL, RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />A EIQt(ICESrri/ITAL R . 0 DS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />r s •
<br />r)M.A.IIIke' r ,.
<br />SARAH BOHNENKAMP,
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES,.
<br />STATE OF NEBRASKA - DEPARTMENT -OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE 9F PEATH
<br />D st4110,,cetTERRtTORr OR FOREIGN COUNTRY OF BIRTH
<br />tAL egCir7Rl
<br />(If nott t{tiBM�tiorl,'gh7• street and number)
<br />TY=Ft; I!?13 I'## Iritiiadtt Zip Code)
<br />O:88•2'4
<br />�rIE�+BT 9b. COUNTYk; r .. Hall
<br />[UTAt trail A EATH 0 Married ® Never Married
<br />anted 0 Divorced 0 Unknown
<br />Ytts, fio; or#1nIt. i 0
<br />est, Suffix)
<br />8a. AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ Eft/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />2. SEX 3. DATE
<br />Male / AuRkst.
<br />5c. UNDER 1 DAY 8. DATE Qir
<br />MINE.
<br />July 141
<br />OTHER 0 Nursing Horne/tit
<br />® Decedent's NttKys-. `
<br />❑ Other fSpsY)' ... .
<br />HOURS
<br />8d. COUNTY OF DEAT
<br />Hall
<br />be. APT. NO: ' 9f. ZIP CODE
<br />� f 68824
<br />lob. NAME OF SPOUSE (first, Middle, Last, Suffix) If wife, give
<br />14a. INFORMANT -NAM
<br />/ Wesley Janssen
<br />UNERAL DIRECTOR SIGNATURE
<br />Timeree L Andreasen
<br />6d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />12. MOTHER'S -NAME (First, Middle, Maiden Su
<br />Bernice Hglister
<br />mg AND MA LIf,I#3 ADDRESS (Street, City or Town, Sfste)
<br />rri n. Funeral Home, 601 N, Webb Road, Grand Island, Nebraska
<br />8D LICENSE NO,
<br />1390
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />bastes, units, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />I11111t1pn ividiout showing the etiology. DO NOT ABBREVIATE, Enter only one cause on 4 line. Add additional lines it necessary.
<br />�EDtA1E CAUSE:
<br />ttkown Natural Causes
<br />Q, OR AS A CONSEQUENCE OF:
<br />IQ,;iIR AS A CONSEQUENCE OF:
<br />ERG lMG CA13Sk',' C y er iSSion
<br />urvthat'tndiaotd . ..
<br />OR AS A CONSEQUENCE OF:
<br />rtphoedema
<br />T=ILsR k#R GNIPI11ki IT #ONDi.T1ONS-Conditions contributing to the death but nattssuiting in tfla underlying cause given in PART t.
<br />OrjiYr!«81n4ett-�NItAHIi.Htlt
<br />tltt,lirtlgrglids"5r:e!f9listit Wtairt 4•2 Oa1^
<br />let#ngdetl4 MICei�pl t#+• . dada »,1 Y
<br />N�sncrSn, ii.?.++Ie iiiir jfa,riai+t•y.�i
<br />M! t3 t31 R1(iMa...D)ly. Yrj .
<br />21a. MANNER OF DEATH
<br />gl Natural 0 Homicide
<br />0 Accident ❑ Pending immatigation
<br />0 Suicide ❑ Could not be determinglr
<br />22b, TIME OF INJURY
<br />lb. IF TRANSPORTATION INJURY 21c. W,&S A
<br />❑ DnvyrlOperator
<br />❑ Paes►ng.r [TITS
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE A{
<br />TO COMP
<br />0 YES '
<br />22c. PLACE OF INJURY -At onto, farm, street, factory, office building, co
<br />HOW INJURY OCCURRED
<br />Day, Yr.)
<br />APT.NO.
<br />CITY/TOWN STATE
<br />23c. TIME OF DEATH
<br />ceurr.d at the time, date and place
<br />Inure and Title) '
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME
<br />August 11, 2025 Air
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME
<br />August 6 2025 ri i
<br />24e, On the peels of examination and/or investigation, in my op
<br />the time, date and place and due to the camels) stated. ($
<br />Matthew Alan Works, Deputy Hall Count
<br />U, •: Qt ?R18LI O THE DEATH? 26a. HAS ORGAN OR TISSUE DONN CONSIDERED? 28b. WAS CONSEN
<br />UNKNOWN 0 YES E] NO Not Applicable If 281 Is
<br />fiL1 D3Df;" SA .t,RIIF a (Type or Print
<br />n ,1l rks , eputY Hall County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68801
<br />I1 �l�is
<br />aliNA7URE •;
<br />)'as�' rc rr.r'FA-4.-—
<br />28b. DATE FILED SY RE$S
<br />August 12.202-'
<br />
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