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<br />STATE OF NEBRASKA
<br />41/1211 p,xa.;,>.. so28G741Yt;IxCNJSFa: _w.rt/,,.4n\\\
<br />ri(S. COPY CARRIrS TjHE i?AISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO
<br />UE:CGPY:.GPTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />f: I? SOON II IA
<br />Anrlel:::.N11 rfe POridOo
<br />202600018
<br />7 /5,44tLete,t
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF'JEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Middle, Last, Suffix)
<br />or,
<br />4, crTY A,ND STAVE OR "rER,RI1'ORY, OR FOREIGN COUNTRY OF BIRTH
<br />,:'�toclt;,t+tettr�slta' :::'
<br />1<`'S<kCt1tL E50.41"fNU00t
<br />-4 2494
<br />Sb. FAC(LITY•NAME pf not give street and number)
<br />Sc; CI t OR.TOW.N.G
<br />Marq.tr> tte 6 "
<br />. RESIDENCE -STATE
<br />EATt (Include Zip Code)
<br />it6 S tk I A#1p,:NUliNeEtE"';:'
<br />Tt?.St>'Iaul: Road::.,
<br />10a MARITAL STATUS AY T161
<br />0 Married, but
<br />9b. COUNTY
<br />Hall
<br />ATH ❑ Married ❑ Never Married
<br />0 Divorced 0 Unknown
<br />:f tpATftiffES-NAME (Flr I,", Middle, Last, Suffix)
<br />tJ. EVER IN U,S.ARMEi'}I FORCi;;8? Give dates of service if Yes.
<br />(Yes; No, or Unk.) NO
<br />15.=
<br />'Mudot..:':."4 Donation'
<br />C] t ierlrlitiori>: t Entombment
<br />{ Removal ' other (Specify) '
<br />!NE#rAl;
<br />I�ra'rt:
<br />arre
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />88
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />lea. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />Sc. UDDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE
<br />Juna 16l,,
<br />e. DATE OF lr
<br />,J
<br />\OTHER ❑ Nursing Hems/LTC
<br />0 Decedent's Home
<br />J Other (Spsclf) )Da‘i
<br />6d. COUNTY OF DEATH
<br />Hamilton
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give midden
<br />Harlan R Puncochar
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Esther, Suohrue
<br />14a. INFORMANT -NAME
<br />Barb Olsufka
<br />18a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlaw1 Memorial Park Cemetery
<br />AME:AND MAILING ADDRESS (Street, City or Town, State)
<br />tap (, 3p05 S. Locust St., Grand Island, Nebraska
<br />16b. LICENSE Is).
<br />1092
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH tSee Instructions and examples)
<br />icdl.,, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />fxnelstion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />MEDIATE CAUSE:
<br />Chr'Onic Respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Iauylist cenQdionP it 4) pWinonaryfibrosis
<br />hy, Iwtdstg tq tuts t0u*l lis1ld `.' .
<br />onth . '
<br />"UETf�OR AS A CONSEQUENCE OF:
<br />Enter MO IJNOERLYINO CAtfal
<br />(dytawe,je injury that Initiated
<br />the y4enteresulttlig In destt0„ • DUE TO, OR AS A CONSEQUENCE OF:
<br />PARTA,Q
<br />hypothyrold
<br />R'SIG:N NECANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in P
<br />htitral regurgitation, hypertension, anxiety, obstructive sleep apnea, osteoporosis
<br />but pntprNtnt.. within 42 days of death
<br />ens, buF plegnaM 42, days to 1 year before death
<br />aniwitt N p$lrlsM witpltlthe past year
<br />22d.INJURY AT WORK?
<br />[]:YES,''
<br />6;
<br />27.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21tr (F TRANSPORTATION INJURY
<br />DnwriOparator
<br />© Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />14b. RELA
<br />1
<br />June 20. Z925
<br />ART i, 1s
<br />OR t~!
<br />0
<br />21c. WAS AN AU
<br />CI Yes
<br />21d. WERE AUT
<br />TO COWLS
<br />0 yes
<br />22c. PLACE OF INJURY At)lome, farm, street, factory, office building, co
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OFSIJURY; STREET S. NUMBER, APT.NO. CITY/TOWN STATE
<br />A
<br />26a. HAS ORGAN
<br />0 YES
<br />23a, DATE OF DEATH (rtfti, Day, Yr.)
<br />June 16,' 2925 ' . „ .
<br />Z b.DATE SIGNED(Mo.,Day„Yr.) 23c. TIME OF DEATH
<br />Jti'nt 2a4025 10:39 PM
<br />gSIG:'Ta thr,beit'ef n446E stodge, death occurred at the time, hate and place
<br />and dies td'tfii:bwse(H stated. (Signature and Title)
<br />,y C.-Anderson, MD
<br />fr��CIJ: S ,GCRNTR ELITE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />ANDAD} ESS`Oil,CERTIFIER(TypeorPrint
<br />Anderson, 'MD., 729 North Custer Avenue, Grand Island, Nebraska, n8803
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo„ Day, Yr.)
<br />24b. TIl
<br />24d. TIME.
<br />24e_ On Ms beats of examination and/or Investigation, In my spans*
<br />the lane, date and place and due to the causalsl statedIll
<br />1a
<br />' DONATION SEEN CONSIDERED?
<br />7 e
<br />26b. WAS CONSENT
<br />Not Applicable If 26a le NO
<br />26b. DATE FILED BY
<br />June 23, 2025
<br />
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