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<br />EAt;115' COPYAR1tf`ES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A'TALIE COPY; i F THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />MAN SERVICES, VITAL.?ECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />5
<br />ASKA
<br />.Red: CiQt1d ..t'ilebrsska
<br />ir<;5 AL• $E UIt;I7YNUMBER
<br />RMilDENCl
<br />Nebraska
<br />202600640
<br />✓+-4147k4-�
<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 />CERTIFICATE OF DEATH
<br />st, Suffix)
<br />IY OR FOREIGN COUNTRY OF BIRTH
<br />et and number)
<br />9b.COUNTY
<br />Hall
<br />1zilTA i *AT.. OF DEATH Ed Married 0 Never Married
<br />d It+ ( WidoWad 0 Divorced ❑ Unknown
<br />(FI lit;',';; Mlddts, Last, Suffix)
<br />5a. AGE - Last Birthday • b. UNDER
<br />76
<br />8a. PLACE OF DEATH
<br />HOE PITAL ; Overtime
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. $EX 3. DATE
<br />Male Fo n
<br />1 YEAR 5c. UNDER 1 DAY IL D;A*
<br />MOS. DAYS HOURS MINS.
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Noma
<br />0 Other (Specify) '
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Susan Andrews
<br />14a. INFORMANT -NAME
<br />Susan Thomsen
<br />a. FUNERAL DIRECTOR SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER'S -NAME (First, Middle, Malden Su
<br />Adeline Mennenga
<br />kl. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />(lb. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Gibbon
<br />FUME 'fitiljly t*ME"AND MA8JHG ADDRESS (Street, City or Town, Stets)
<br />if'>*8ittts;F rome, 2Si29 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and xamrdes)
<br />t) teems dF�eaaa. kylnlee, ar ar+nMlset±ernr that directly caused the loath. DO NOT er er terminal averns Hoch m cardiac arrrct.
<br />14ePiititNC)! ePtaPty.O{ outer twrixettay wkhout showing the etiology. DO NOT ABBREVIATE. Enter only one catNH on a Sine. Add additional lines If necessary.
<br />IMMEDIM'E CAUSE:
<br />1EcMs131iknown Natural Causes
<br />OIFt AS A CONSEQUENCE OF:
<br />iU(I TO, OR AS A CONSEQUENCE OF:
<br />AS A CONSEQUENCE OF:
<br />�T CONDITpNS•Condidons contributing to the death but King
<br />lesterolemia, Early -stage Renal Failure, Emphysema
<br />43 days or death
<br />R to t year before death
<br />,1HIy, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homic14e
<br />❑ Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could not De determined
<br />TIME OF INJURY
<br />the underlying cause given in PART 1.
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN
<br />priver/Operator
<br />Ppitenyer CI Y
<br />0 Pedestrian
<br />0 Other(Specify)
<br />22c. PLACE 01 (NJURY-At home,farm,
<br />IBEHOW INJURY OCCURRED
<br />T • NUMBER, APT.NO.
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />cumd at the time, dab and place
<br />Leff and TkN)
<br />ft?8>CSXf: ONrltitsttME TO THE DEATH?
<br />Ye s t4t3 "is :.`PRQ1lA,B,.aL,V UNKNOWN
<br />E,'i fit NC Ells 11JF C$RTI'FI R (Type or ant
<br />coil, Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26a. HAS ORGAN OR
<br />0 YES
<br />21d. WERE At
<br />TO COMP
<br />0 YES
<br />tint, factory, office building, construct)
<br />STATE,
<br />24*. DATE SIGNED (Mo., Day, Yr.)
<br />November 11, 2025
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIN
<br />Noyember 2. 2025
<br />24*. On the boils of examination and/or Inveatigatlon, In my
<br />the time, dab and place and due t0 the csus,(s) stated.
<br />Martin Klein, Hall County Attorney
<br />SUE DONATION BEEN CONSIDERED?
<br />® NO
<br />26b. WAS CON$ENt
<br />Not Applicable if 24s !s N
<br />28b. DATE FILED BY R
<br />November 12, 2025,
<br />
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