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<br />202507010
<br />120
<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 OF QEATH
<br />(Prier',. Middle, Last, Suffix)
<br />Garritlr
<br />31 i<T8 CAt 3E (Final : ;.
<br />itkor,con l(len`resunin
<br />5egnendaliy list eondlions, If
<br />}.+.tyi:lee4M9to:tka eauee ik(iitd::::.:
<br />itJ
<br />SteerIt,UNltE8L sI..I:::CAu$:
<br />'(disease eratjuty thatlietiated
<br />the events retuning in death) DUE
<br />LAST .... ... )
<br />STATE OF NEBRASKA
<br />f strc,traganyc.>., z'=(4 ))))Yi"1Naato <.._. _.__..
<br />E? THIS COPY CA RI S THE RAISED SEAL OF STATE OF 11 EBRASKAx IT CERTIFIES THE DOCUMENT BELOW
<br />A TRUE; OP OF THE'ORIGiNAL RECORD ON FILE WITH Tilt NEBRASKA DEPARTMENT OF HEALTH AND
<br />• HUMAN SERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />D :TfQFX'Sii l
<br />9/2g 0$
<br />LA/cm" Igq.BRASKA
<br />tiEC$QEI+l:;1�8-Ni
<br />ar)1i :'st::ra
<br />4:C1TY ANF3'STATE'iR 1RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />..Sa r9ent,. Nebraska
<br />SOCIAL S.Ou„ t?rY NtihtBl
<br />505.74'-...642:
<br />bb. FACILITY.NANiE Xtf not Institution, give street and number)
<br />:::Grand;Island.:Req\ienal.Medical Center
<br />Sc'>etTY<OR TOWN •D AT
<br />t rad<:Islanl
<br />9a. RESIDENCE -STATE •
<br />'..;Nebraska
<br />Sd';STREETANDNUMBf
<br />Te tale Ave: >°'..
<br />Zip Code)_
<br />9b.000NTY
<br />Hall
<br />AL`BTAFTUS'AT FIME OF DEATH I I Married 0 Never Married
<br />led, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />I'E-NAU
<br />J:'GBrI
<br />(Flhet, Middle, Last, Suffix)
<br />1'3'.. EVER'tfF'U.S: A'RMEi) FORCEB?
<br />(Yes, No, or Utgc.y14p
<br />19:. b1ETR.S.SSF D(SPOsiYIION
<br />ROI
<br />Oremlittvn <:::: ;;t ttor(drrint
<br />RamOVal' 'D ottier'ISpaolfy)
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />72::::
<br />Sti UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />`MOS.
<br />i
<br />ea. PLACE:OF DEATH
<br />HOSPITAL El:lnpatitarst : OTHER 0 Nursing Homo/LTC
<br />❑ ER/Outpatient 0 Decedent's Home .,
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE
<br />Se
<br />6. DA
<br />0:PO4. :
<br />9c. CITY OR TOWN
<br />. Grand Island
<br />0 Other (Spec(Rr)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />Of. ZIP CODE
<br />68803
<br />lab: NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give toot
<br />Tamra Franzen
<br />12: MO.:THEINAME (First, Middle, Malden Sum
<br />Shifty Jean' Alexander
<br />14a. INFORMANT -NAME
<br />Tamra Garner
<br />lea. FUNERAL DIRECTOR SIGNATURE:
<br />Caleb J Alcorta
<br />6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1T ...FUNL(3AL:HOM;E NAME:AND MA LING ADDRESS (Street, City or Town, State)
<br />All.Faiths Funerall.Horrie, 2929 S. Locust Street, Grand Island;' Nebraska
<br />{Er
<br />oty arrest,
<br />• 1:5b LICENSE NO.
<br />1$07
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH iSee Instructions and examples)
<br />•diseaeee, /n)uriea, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />cubit fibrillation Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />piratory failure
<br />, OR AS A CONSEQUENCE OF:
<br />static colon cancer
<br />, OR ASA CONSEQUENCE OF:
<br />0, OR AS A CONSEQUENCE OF:
<br />PAF IL OTHER'BlGiV1FICA CONDITIONS -Conditions contributing to the death: but rtOt res.Ulting In the Underlying cause given in P
<br />.tEis;#f FEMALE; ..::::: :::.:.
<br />;ne+i; Not pr►511111I in peal year �
<br />Pitt vrny ;artttitt/Seth :<'L
<br />._ `pt gnant, Ittitinregnanwithin 42 days of death
<br />but pregnant 43 days tc 1 year before death
<br />Shown if ixeptlard tvili in;tgi pact veer
<br />; #a PATE Og:e.Ltvl
<br />22d, FURY Al WORK/
<br />[ TES
<br />OF HQ
<br />21a. MANNER OF DEATH:
<br />® Natural ❑ Holniyido
<br />0 Accident ❑ Pending Investigation
<br />O Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2 tb. IF' TRANSPORTA710N INJURY
<br />Drrverlllperetor
<br />0 Paaaarlyor
<br />0 Pedestrian
<br />❑ Other (specify)
<br />22c. PLACE OF:INJURY-AthOmO 'fd
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />T i NUMBER, APT.NO,
<br />3e, PATE OF DEATH (Mo.; -Day, Yr.)
<br />September 22, 2025
<br />DATE. I 23ri.. S GNED. Mo,D Y.
<br />t , r
<br />Day, }
<br />gieMbl tIT: 20 5
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:03 AM
<br />ka;:# eat of it?) ieWtedge, death occurred at the time, data and place
<br />des 4:b Ii,P< „;a(t) etarad. (signature and Title)
<br />c,�. Berg, MD
<br />2 0r0 pt.occo U3
<br />teaac's
<br />14b. REL
<br />Spouse
<br />16c.
<br />Sep
<br />x 2•
<br />ART I. 19. WAS
<br />OR O
<br />0 YES
<br />21c. WAS AN AUTO
<br />❑ YES
<br />21d. WERE AUTOPSY
<br />TO COMPLETE
<br />❑ YES
<br />;;street, factory, office buildiy, construction ice,
<br />\STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />��
<br />24; on the easrl%' ) i examination and/or Investigation, in my -op(
<br />tM time., date and place and due to the ousels) stated« Si1
<br />24b. TIME OP
<br />24d. TIME Flgpi
<br />26a, HAS ORGAN OR - - e s AllON BEEN;O
<br />❑ YES Ii NO
<br />Nu EEO1 ES$ 6 CERTIFIER (Type or Print
<br />q{"729 North Custer Avenue, PO Box 2339, Gran. Island, Nebraska, 68803
<br />40'£ tiaUTl€ TO THE DEATH?
<br />Y 0 UNKNOWN
<br />ONSIDERED?
<br />28b. WAS CONSENTS
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BYREGIS
<br />September 25, 2
<br />.'i7,'lr__.... r�� w>. .<»2rr,49S�Jeps�•��'i�itt/r 11I4tk0
<br />
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