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CI N. ilAt+I::'tFirst, Middle, Last, Suffix)
<br />beWitte
<br />STATE OF NEBRASKA
<br /><�ttareafcaaa;f�
<br />•WHEN THIS COPYCARRIES'THE RAISED SEAL OF STATE OF NEBRASKA, It CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUECOPY'OF THE,ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />-HUMAM'SERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202600581
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF QEi TH
<br />AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />braska
<br />iEE F:A ND NUMBi R
<br />k''Street
<br />ARITAL ST/kTUS AT
<br />11,°FATNER'S-NAME (First,.,
<br />Hubert::: Harold :Mite
<br />EVER ilf U f3. ARMED FOR€
<br />('ramNo, +r{1nk.)Yes
<br />1 .1M I#1OD onaI11OOF'WSPOSN
<br />]'Burial:. ;..0,Dthi(1'>r
<br />C Creetf`ItltTn; Q�Entantbttttxtt
<br />},' Rt moval 0 Ot er ( di
<br />lie. `FUNS tAL HOME. NAME AND
<br />All Faitl s-Funerral:Home,
<br />9b. COUN
<br />Hall
<br />TH RI Married 0 Never Married
<br />red [] Divorced 0 Unknown
<br />5a. AGE - Last Birthday fi
<br />(Yrs•) MOS. DAYS
<br />73
<br />8a. PLACE OF DEATH, /
<br />HOSPITAL 0 Inpatient
<br />0 ERlOutpatlent
<br />0 DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc.
<br />UNDER 1 DAY
<br />HOURS
<br />3. DATE OP DEA'
<br />OTHER ❑ Nursing Haan<€7
<br />0 Decedent's Hans ,
<br />® Other (sP�arx)t on
<br />ed. COUNTY OF DEATH
<br />Howard
<br />5s. APT. NO.
<br />9f. ZIP COD
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife,
<br />Colene J Westwood
<br />14a. INFORMANT -NAME
<br />Colene J White
<br />a' FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Veterans Memoria Cemetery
<br />JNtA ADDRESS (Street, City or Town, BMW/
<br />9 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (bee instructions and examples)
<br />MOTHER'S -NAME (Firs Middle, Maiden
<br />Maxine Myrtle SchI ICh
<br />fib. LICENSE. NO.
<br />1439
<br />r (hi ci a(°sw . itatMeoe,IWudea, or e,nmhlcallode-that directly caused the death. DO NOT enter tomdnal events such as card arrest,
<br />Mr Ft. pf 4eal)ktl rut showing the etiology. DO ffOT ABBREVIATE. Enter only one cameo on a line. Add additional lines a nowarrary.
<br />IMMEDIATE CAUSE:
<br />,Ua t lA+l a)Cerdkl-Pulmonary Arrest
<br />PART A. THER #1 NIR
<br />spirafion neumonia, I
<br />DUE TQ, OR A$ A CONSEQUENCE OF:
<br />b) Chton)C Obstructive Pulmonary disease
<br />RASA CONSEQUENCE OF:
<br />AE A CONSEQUENCE OF:
<br />T CONDITIONS-Condklons contributing to the death but not
<br />tiri Calorie Malnutrition
<br />pregna d within 43 Wye of death
<br />pragiihnt" days t# 4 yee before death,
<br />iatt iVlarhi the pUl year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />Suicide El Could not be determined
<br />TIME OF INJURY
<br />Ind in the underlying cause given In P
<br />lb. IF TRANSPORTATION INJURY
<br />DHvivioperator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY-AttlonM, farm, strelt, factory, office building, cone
<br />IBE HOW INJURY OCCURRED
<br />December, 2025 .
<br />b,:DATE SIGN FD.(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />�Q rnbo 17 20t25 10:50 AM
<br />. lb. best of my knowledge, death occurred at the time, date and place
<br />''"Lid�due to the ceuse(alstated. (Signature and 'nos)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr,)
<br />TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONA
<br />SLY UNKNOWN ❑ YES ®NO
<br />CERTIFIER (Type or Print
<br />Fairgr MQ, 205 $ Lincoln Ave Ste 101, York, Nebraska, 68467
<br />•
<br />7n the hens of euminetlon and/or Ines igatfun, inwry'i
<br />the tine, date and place and due to the causes) stated.
<br />N BEEN CONSIDERED?
<br />2sb. WAS CON
<br />Not Applicable If
<br />26b, DATE FILED B'
<br />December 2
<br />b. UNDER 1
<br />YEAR
<br />
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