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STATE OF NEBRASKA
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<br />At:TI IS COPY.CdARRf THE RAISED SEAL OF STATE OF Ni B ASKA,:!T CERTIFIES THE DOCUMENT BELO
<br />`/[ TRUE corrOF'} OptVO1NAL. 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 />tore cif 15s eb.
<br />9f t 512P2
<br />INCOLN,NEBRASKA
<br />C1ENT!;37IifA .(first:;;:;;: 111itlsbe, Last, Suffix)
<br />rrbara' °':Cfitich[.>:
<br />2025071 8'.:
<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 />CERTI:FICATE:.;OF DEATH . N
<br />$'.CITY AND STATE OR RRITORY, ORFOREIGN COUNTRY OF BIRTH
<br />Pttdlps Courity:,'Nebraska
<br />CIAL SEc nittrY NUMS1 R:i
<br />Gb. FACILITY -NAME
<br />tinstlti
<br />on, give street and number)
<br />Grand'#skand.l epional,MediCal Center
<br />Gd, CITY;OR:T ; ?F Deivn ((netyd. ZIP Code)
<br />''Grarttl:tsland 688t t'::::
<br />9a. RESIDENCE
<br />:i:Nebras:ka
<br />TATE
<br />9it':STREET'AND:N MBER'
<br />606 Arrowhead' `:`
<br />9b.000NTY
<br />Hall
<br />fa.. MARITAL STATUS AT"TIME OF DEATH ® Married ❑ Never Married
<br />0 M*nled, but 'operated 0 Widowed 0 Divorced ❑ Unknown
<br />t;1:>ATHERktfNAME (Fti1)t dle, Last, Suffix)
<br />13. EVER'.Ifi)'U &ARMED'
<br />(Yes, No, or Unit.) No
<br />'16,..V.MHODOF Dl
<br />i Syria►
<br />Ottonvisp�( j ntomb
<br />❑ Remov ll, ! Q'Other {S
<br />114:.FUNEfRA. ::HE.
<br />tA)) Faiths Fur �i
<br />F
<br />1e. PARt1• Evperthee d
<br />• respiratory treat, er veldt
<br />intt
<br />ment.
<br />pacify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83..::: ..
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Oa. PLACE:.OF DEATH ..
<br />HOSPITAL ®Inpettent
<br />HOURS
<br />MINS.
<br />3. DATE O l
<br />August
<br />6. DA
<br />OTHER 0 Nursing Home/t,TC
<br />❑ ER/Outpatient 0 Decedent's Home
<br />❑.pOA`
<br />9c. CITY OR TOWN
<br />Grand Island
<br />i ❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />APT. NO.
<br />N
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />John Clinch
<br />12;;MOTHER' S-NAME (First, Middle, Maiden Syrn
<br />0ortthv :.)Dhnston
<br />14a. INFORMANT -NAME
<br />John Clinch
<br />6a. FUNERAL DIRECTOR SIGNATURE:.
<br />Daniel D Naranjo
<br />180. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />NAM4A ID MA LING ADDRESS (Street, City or Town, State)
<br />at;Home,,2929 S, Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />aces, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />16b,:LICENSE NO.
<br />:1071
<br />CITY / TOWN
<br />Gibbon
<br />hoot *bowing the etiology. DO NOT ABBREVIATE, Enter onlyono cause on a lipe. Add additional lines If necessary,
<br />EDIATE CAUSE:
<br />Hypoxic respiratory failure
<br />TO, QR AS A CONSEQUENCE OF:
<br />laity list conditions, it bY00ngestive heart failure
<br />tllnp:lo.;ihe csu�e Ihitld:>:;'� �.,
<br />dot theal3MpE RLYiC(9: CA t1i
<br />Iseaso or Injury that initiate
<br />e events resulting in death)
<br />DIE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />1 ..PAR :LO1HERS(GNWLCittfi
<br />20.1FFENA4E;: <:
<br />CI Not ;P*.gn0 1'0100
<br />Pregnantptftmeof da•
<br />DITIONS-Conditions contributing to the death but nott'esytting [n the underlying cause given in PART I.
<br />.. Not prapnant, Put pregnant Moth 42 days of death /
<br />❑ Not eminent, but Pregnenl4a days to 1 year before dead(
<br />. ❑ Utlkttuiwn t5pre5llaiq viiplin the past year
<br />2ai DATE OIi1NJU#t'1t.t1Y[asCFay; Yr.)
<br />22d. INJURY AT WORK?
<br />�..: Ott'tocstrtat�!'ti�';iti.Ut��.
<br />21a. MANNER OF DEATH'.
<br />® Natural ❑ Homicide:. .
<br />❑ Accident 0 Pending investigation
<br />0 Suicide ❑ Could not be deterntned
<br />22b. TIME OF INJURY
<br />210.1FTRANSPORTATION INJURY
<br />El Driv ribparator\
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATION
<br />Spouse .
<br />16 . DATE -I
<br />Aupvst`,
<br />on
<br />19
<br />21c. WAS AN AU
<br />El YES
<br />21d. WERE AU
<br />TO COMPt.
<br />❑ YES
<br />22c. PLACE OF INJURY -At bowna; tarot: street, factory, office building, constmetiorl s'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />BER, APT.NO. CITY/TOWN
<br />DATE OF DEATH (No:, Day, Yr.)
<br />August 26r 2025
<br />2 b; PATE 91dN...... 1o., Day; Yr.)
<br />i::.. 23c. TIME OF DEATH
<br />'02 12:31 PM
<br />:.
<br />yd.:TiYih►:Ayittdt�itiY;M•Qtle, daatP occumdated at the time, and place
<br />.:.':: rhist0 theeeeti+WNtets) hated, (signature and Title)
<br />Mitchell D'kiervert, MD
<br />Y.
<br />O)A TtENtilCO;ifSE.E
<br />:YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />:;4c;;P,RONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.'IME
<br />24d. TIME PRO
<br />24e, OrI tha'Idsch:oi examination and/or investigation, in trey opiniot
<br />• the time, date and place and due to the cause(') stated. (e
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO:
<br />AMEt. I E ANf1';'ADDRREESS op CERTIFIER (Type or Print
<br />itchell b I4 rveit,'MO,. 3533 Prairieview St, Grand Island, Nebraska, 68801
<br />RI:BUTE TO THE DEATH?
<br />PROBABLY ❑ UNKNOWN
<br />RS S(GNATUREE..
<br />C '24 t7 ���L nyrr -ric ry
<br />26b. WAS CON
<br />Not Applicable If 26a Is NO
<br />28b. MATE FILED BY RE
<br />September 10, 2026
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