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<br />STATE OF NEBRASKA
<br />`$b'iu"t =
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<br />WHEN THIS COPYCARIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRLJE OPV OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL, RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAM OF ISSUANCE
<br />e25r2fl2
<br />LiNCOLN, NEBRASKA
<br />2 0 2 L . 4.46 wit V 6 SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEDE$T':S-tFJtME::NEiret, , Middle, Last, Suffix)
<br />DO»na 3 :COle :::: •'"
<br />4. CITY ANC' STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />:::grand 1sland:.Netaraska
<br />.a"i SOCIAL SECURITY NUMBER
<br />507::34 510J;::.. ::; ))))
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />::.:Tiffa.rw Square Care..Center
<br />Se. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand .land.):688IS3'
<br />9a. RESIDENCE -STATE
<br />;.Nebraska .
<br />8tl STREET,ANDNUMBER`;
<br />811:.E. ;Delaware'Ave
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but sriparated 0 Widowed 0 Divorced 0 Unknown
<br />11x:FATHER'S•NA:ME (first;:)'.:: Middle, Last, Suffix)
<br />DeVefn:" Stahlnecker
<br />13. EVER IN U.S. ARMEDFORCES?
<br />(Yes, No, or Unk.) No
<br />18. •METHOD:OF DISPOSITION
<br />W 0. ametton .j:Entombment
<br />❑ Removal ❑ Other (Spaclty)
<br />5a. AGE; Last Birthday
<br />(Yrs.)
<br />93
<br />db. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a..PLACE OF DEATH
<br />HOSPITAL ❑:Inpatient
<br />0 ER/Outpatient
<br />❑°DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />t"t
<br />3. DATE OF DEAfifN (Mf..Di*:1
<br />August 17, 2025;::>
<br />8. DATE OF PIR
<br />Day, Yr )
<br />February 14493.2:
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Horns
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e, APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />N
<br />M:Pael(II
<br />iN8100. CtTY1.tlt#tTS
<br />tlYES ."!1 0'
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Addison Lewis Cole
<br />12, MOTHER'S -NAME (First,
<br />Opal ..Gross
<br />14a. INFORMANT -NAME
<br />Addison Lewis Cole III
<br />18a. FUNERAL DIRECTOR SIGNATURE
<br />Caleb J Alcorta
<br />19d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />1:.1s> Ft#N.R. L H IE NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br /><':All:i=aitl )Furleral:Home, 2929 S. Locust Street, Grand island, Nebraska
<br />CAUSE OF DEATH (See in
<br />18b. LICENSE NO.
<br />1607
<br />Middle, Malden Sum
<br />CITY / TOWN
<br />Grand Island
<br />ructions and examples)
<br />111. PART I. Enter the chainnts-, diseases, injuries, or complications -Mat directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter on y one cause on a !root. Add additional lines it necessary.
<br />::;:: IMMEDIATE CAUSE: /
<br />w e R1EcAU$E: pirm)::;:; a) Renal Failure
<br />dlsusi Or.00011lan,)`4iaOng :k
<br />In death) DUE 70, OR AS A CONSEQUENCE OF:
<br />Sequentially list condktons,, If b)Stroke
<br />so, Iaailtfig 40 4h. eft :ja NetRd: l ^
<br />::pil'linrr:a`
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />Enter m i gieetvi CRuae C) Atrial Fibrillation
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />f RT IL OTHEIt
<br />DUE 70, OR AS A CONSEQUENCE OF:
<br />d)t4ypertension
<br />IGNI.GANT CONDITIONS-Condidons contributing to the death but::not.td.ulting.in the underlying cause given in PART L
<br />zti. IF FEMALE: .
<br />Not>pregn>;ie wit /n piisj' year';>
<br />::..❑ Pripm)1 et tlm. st liens:.:
<br />0 Not pregnant, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year bottom death
<br />>:❑ Ufkiiown./1 praynam etttlin:tl4e past year
<br />TE tkFiN lURY:(Mo.,Day, Yr.)
<br />22d. INJURY AT WORK?
<br />21e. MANNER OF DEATH.
<br />® Natural ❑ Homicide.>
<br />❑ Accident ❑ Pending lnvestiganon:.
<br />❑ Suicide ❑
<br />22b. TIME OF INJURY
<br />Could not be determined
<br />22e. PLACE OP:1NJ
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />22r. L0 AT1ON QF,INJURY, STREET# NUMBER, APT.NO. CITY/TOWN
<br />2
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 17, 2025
<br />230. DATE:SIGN:ED,(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />>`}Igst 0. 2025 08:30 AM
<br />`23d; To nif kitistd#:ttly kttowledge, death occurred at the time, date and place
<br />,:.:'.'and *Rio tit i 4ause(s) slated. (Signature and Title)
<br />Kenneth Vettel, MD
<br />DID:. TOBACCQ:USE:.CONNTRIBUTE TO THE DEATH?
<br />YES:;8/0`':>?:0::PROBABLY 0 UNKNOWN
<br />.21.b.:*F: TRANSPORTATION
<br />0nverl0perator
<br />Ptansrtger
<br />0 Pedestrian
<br />❑ Other(Rpecify)
<br />INJURY
<br />Y-At home earn, et
<br />14b. RELATIONSHIP
<br />Son
<br />tes.Doe (Mo, Day,?fr)
<br />August 21, 8
<br />STATE
<br />Nebraska
<br />1713.Z1p...
<br />68801
<br />APPRQXIMAiBINT I IAL
<br />onset to
<br />2 Weeks>
<br />onset to death
<br />1 Year;.::
<br />most toitriss).:
<br />5 Years
<br />-r-
<br />19. WAS MEDICAL axs,sgNVEIi.:::
<br />OR CORONER CONTACTED?
<br />Q YES Ea NO
<br />21c. WAS AN AUTOPSY
<br />❑ Yes ®' NO
<br />RFORMED?`::;'<k
<br />21d. WERE AUTOPSY FINpING1 AIIAILABL,E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NOk ... .. ....
<br />, factory, orrice building, construction sits,.
<br />STATE ..?....ZIi).)cOfJB
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />244. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED:.D
<br />24e.On ttti belli of examination and/or investigation, In my opinion
<br />the time; date and place and due to the causes) stated, (Mgnature
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES al NO
<br />27. NAME, Ma AND AD# RESB OF CERTIFIER (Type or Print . .
<br />Kenneth Vetted, MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR $.SIGNATURE
<br />26b. WAS CONSENT GRANTS
<br />Not Applicable If 26a Is NO
<br />28b. DATE FILED BY REGiS
<br />August 21, 2025
<br />)
<br />:, PS!,'Yr,)..,:.,.
<br />
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