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ON:TRIBUTE TO THE DEATH?
<br />RICOEABLY 0 UNKNOWN
<br />:1.1.h`�t);1;AQj:i>;•;ir:P::A3iS:,:L,r;%::2(1r%r�I1r.fdfifff11f.11.111�„a,,)`.+.3;�•:N:aa������<f..�..v.r.r.r._S_TAT.._ EAOF NEBRASKA
<br />.... ri��a:;tF4liiiCaYi:a3lipl ttp.sueN17a11iht:a
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<br />COPY;GA ES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW T
<br />A RU COPYOP rHE 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 />DATE OF ISSVANCE
<br />L/NCOLN, NEBRASKA
<br />t 7ECEDE$ . NAME IFIre.
<br />Marvin> ►ern Peters
<br />202601554 AS ms.
<br />SARAN BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE, OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATES OF DEATH
<br />e. Last, Suffix)
<br />CITY ANDSTATE:'OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />::Gra nd. lsland...Nebraska
<br />S CURtTY NUMBER:;
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />$b. FACILITY -NAME (If riot Institution, give street and number)
<br />Tablets , t Prairie Gammons
<br />SC. G tY C R for >; F DEAT .ttnclude Zip Code)
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />1i
<br />9b. COUNTY
<br />Hall
<br />STREET'AND NUMBER
<br />349Q Ew&dl t:
<br />ARITAL STATUS A7"TIME OF DEATH ❑ Married 0 Never Married
<br />Married, but separated 511 Widowed 0 Divorced 0 Unknown
<br />tt' KATNER'S.NAME< (FIrat:; ".:; Mtddls, Last, Suffix)
<br />F: <Petera
<br />.'EVER IN E) S. ARMED .. CES?
<br />(Yes, No, or link.) Yes
<br />'15. METH0D OFF D ap.pajpoN
<br />DDonattcri?>'
<br />;:':" Grit tulffalti Stitgn lam fit
<br />[ ] Rei»ovei laothiati (Spbcity)
<br />89 .:
<br />5ti: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a. PLACE OF QEATH'
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑:DOA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE
<br />November 4, 2€I
<br />a. DATE OF SIIRT$ (MO
<br />October
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />i
<br />Other (Specify)A$SISTEti`#14N[st:
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be, APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname
<br />A)Vira H Bader
<br />34a.INFORMANT-NAME /
<br />MellSsa Howell
<br />16a. FUNERAL DIRECTOR SIGNATURE.
<br />Brandon S Bachie
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17s.. F'UNERA:t. HOME;NAME;:AND MA UNG ADDRESS (Street, City or Town, State)
<br />;; pfal i^tl t ral:i ome: ;1;'1;23 W. 2nd, Grand Island, Nebraska
<br />1613. LICENSE NO.
<br />1537
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH fSee instructions and examples)
<br />111. PART I. EM#r the chale of avant+,dlaeann, Injuries, dr complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />raspiietory.arrest, or ventricular Rbrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />'::':.i.MMEDIATE CAUSE:
<br />IDIATaCAUSEIPinel ;:<'<' ! )respiratory failure
<br />dial?tit:,w condldon::/WidtttiE:_'�:j <::.�
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially lint conditions, d ' b) dementia
<br />' aaJ Nadin!f.:t? tl» cauorkflotsd
<br />oiiaae r
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />'.Eiaterthe•UNDE$•
<br />I.VINGCAU8£>
<br />• disuse erfakir tturMRfat•t
<br />Ilea rwnts "'suiting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />EAST d}
<br />i ,
<br />s4ai 7`S. OTtmER'. ►ONWICA.o CONDITIONS -Conditions contributing to the death but not reaulting inthe dying cause given In P
<br />non9 ''
<br />2O ::Ig FENCAwE:.
<br />yy Noitiiil�wlilax,
<br />Preaaant dt:liow$4er�
<br />Not PtS5hitht, bntpregnNN.WIthin 13 days of death
<br />Not prranant, but pregnant 43 days to t'yrpr before death
<br />t: p:r
<br />n *Pregnantpregnant aRllie the Peet year
<br />22ii:;DATE;OF:k1J17:RY:1io ;De Yc )
<br />22d. INJURY AT WORK?
<br />DYES ID NO.::,
<br />32I,::;I. OATi0N OF:INJJ
<br />2a DID
<br />21a. MANNER OF DEATH
<br />® Natural El Homicide .
<br />[3 Accident ❑ Pending Investlaatlon
<br />El Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />IF,.TRNSPORTATION INJURY
<br />0 Primmer
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />14b.
<br />16c. DA
<br />Novemb(
<br />APP
<br />1 Yes
<br />onset
<br />ART
<br />1. 18. WAS
<br />OR
<br />❑ YES;
<br />21c. WAS AN AUTOPSY PERF1Jl
<br />❑ YEa
<br />21d. WERE AUTOPSY i4M _
<br />TO COMPLETE CAUSE)
<br />❑ YES
<br />22c. PLACE OF INJURY.At home, farm, streets factory, office building, const
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />UMBER, APT.NO.
<br />2.311.DATE F DEATH (Mo., Day, Yr.)
<br />November 4, 2025 k
<br />23b.DATE SIGNE(.I,Mo., Day, Yr.) 23c. TIME OF DEATH
<br />itiOvern 00'4. 2025 08:59 PM
<br />344. rotes NM Over keov4etlae, death occurred at the time, date and place
<br />::.:<.:'antl BVP4O tittctjus9(s) staled. (Signature and Title)
<br />Isaac J. Berg, MD
<br />24a. DATE SIGNED (Mo., Day, Yy.)
<br />44b. TIME
<br />24c.: PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRON(10
<br />2N:Oft tht:bes/I of examination and/or investigation, in my opkdon'
<br />tee time; date and place and due to the cause(s) staled (rapture
<br />?RSA CO.LtSg C 26a. HAS ORGAN OR TIISSUE.DONATION BEEN CONSIDERED?
<br />_` ;: > .... DYES NO
<br />21ME,;;TITLE AND AT EESSS OF CERTIFIER (Type or Print
<br />Isaac J Seri; IilIL?t`729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska,\68803
<br />TRA
<br />26b. WAS CONSENT
<br />Not Applicable If 26. 1s NO
<br />28b. DATE FILED BY REGIS
<br />November i 8, 202
<br />i�aclftji
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