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<br /><_ _ STA E OF _NEBRASKA
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<br />WHEN -THIS COPY comes 'iHE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE .ATRUE COPY &ME 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 />I
<br />DATE ISSUANCE.'>
<br />6/24i2O25
<br />LINCOLN, NEBRASKA
<br />202601750
<br />zit f. ,,ik .
<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 />'[ DEGEDEt>f :.S RAMS;.).Evil;;;; Middle, Last, Suffix)
<br />Puttcochar
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />. York;; Nebraska.L
<br />T SOCIAL SECU1RrtY PANDER.
<br />505.42.24 .:..:..:
<br />-.8b. FACILITY -NAME (If not Institution, give street and number)
<br />108 Lyon St,
<br />Es CITY OR TOWN OF DEATH (Include Zip Code)
<br />1i Marquette 68854
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />9a. RESIDENCE -STATE
<br />Ne itr .sk9 :::<:>':: . >:;..:.
<br />grit STREET AND NUMBER
<br />3070 St Pail RrAd
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced ❑ Unknown
<br />r =it FATHER'S NAME (First
<br />Jt hri A Neville
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk) No
<br />i
<br />Middle, Last, Suffix)
<br />t6 MET HOD OF DN tio>1
<br />�j'rial Oanatloat;;
<br />0 Csemiatron 0 Entombment
<br />[] Removal 0 Other (Specify)
<br />88
<br />rib. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ca. PLACE OF DEATH
<br />HOSPITAL ❑:inpatient
<br />0 ER/Outpatient
<br />O DOA.
<br />9c. CITY OR TOWN
<br />..Grand )Island
<br />HOURS
<br />MINS.
<br />3. DATE OF BEAM,,1
<br />June 16, 202S:.::.;:
<br />6. DATE OF BIRTH (Mo., Day, W.)
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Horne
<br />® Other ($p60Ify)0atrghtte
<br />I8d. COUNTY OF DEATH
<br />Hamilton
<br />De. A T. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, SuffIxf N wife, give maidatl
<br />Harlan R Puncochar
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Esther Sughrue
<br />14a. INFORMANT -NAME
<br />Barb Olsufka
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />1Fe FUNERAL log I mt AND MAILING ADDRESS (Street, City or Town, Stale)
<br />Cktran funeral Chapel„8005 S. Locust St., Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1092
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions aria examples)
<br />IL PART I. Enter Me chain ofevems• .diseada, injuries, or complicstiona4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respirptory arrek,Or rifi rku(er fiblltstion Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />:IMMEDIATE CAUSE:
<br />catesi;�bwi -.4) Chronic Respiratory failure
<br />In Meth)
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />aequamaiiy set condroon! H b) pulmonary fibrosis
<br />Maduity*the CNNa gated
<br />'I;fUE TO, OR AS A CONSEQUENCE OF:
<br />Eater isiai ataL1lilia CitlltlB' C)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />lA6T .... .. ..... ....::::>:..d)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />'t8. PART If OTHER SIGNIFRDANT CONDITIONS -Conditions contributing to the death but not moulting in the: underlying cause given In PART I.
<br />hypothyroidism, Inlaid regurgitation, hypertension, anxiety, obstructive sleep apnea, osteoporosis
<br />204F FIAALE
<br />!l6ttiri** lMljhinlpNt O tr.
<br />❑ rranantataimanrdws0t::"
<br />0 Not liniment but pregnant within 42 days of death
<br />❑,.Not pregnant, but pregnant 43 days to I year before death
<br />u unseen H pregnant tatlilin ye past year
<br />Aide. t'lATEff>"WOO (Noti;DaY, Yr.)
<br />22d. INJURY AT WORK?
<br />YES [No
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At ho
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LiiCAT10N OF tNJIIRY -emEET & NUMBER, APT.NO.
<br />ll
<br />R
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />June 16, 2025
<br />Ida
<br />CITY/TOWN
<br />Zap, DATESIOFJED;,(Mo•, Day, Yr.) 23c. TIME OF DEATH
<br />IEn k 00r 0P 10:39 PM
<br />:solo the hat efplyknewledge, death occurred at the time, date and place
<br />ad:i0ua to their se(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />21b IPTRJINSPORTATION INJURY
<br />❑. Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSNIM'i'O oteeei wr
<br />Daughter.
<br />18c. DATE (Mo.,Oiy
<br />June 20,
<br />' #ATE
<br />Nebraska
<br />17b„
<br />INTERVAL
<br />onset
<br />Years
<br />onset to
<br />21d. WERE AUTOPSY FINDINGS.AVAILASLI
<br />To COMPLETE CAUSE "OF DEATH?
<br />❑YES ©:::
<br />farm, street, factory, office building, construction sits, etcK
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME`
<br />24e:On the basis of examination and/or investigation, in my opinion
<br />the time, are and place and due to the cause(a) sided. (l)gnahlva
<br />26 OIt1'iOBAC00 [)EE 00WUBUTE TO THE DEATH? Tea. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES NO [.RROBABLY ❑UNKNOWN ❑ YES I� Na
<br />N ErTITLE.A.., AOORtESS OF CERTIFIER (Type or Print ' -
<br />Jay C. Anderson, MD, 729 North Ouster Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRA
<br />Not Applicable N 26a is NO
<br />23a. REGISTRAR'S SIGNATURE
<br />G-t4-.% .8.44aL.A.e7 ->yr
<br />26b. DATE FILED BY REGISTRAR,1Mo.,
<br />June 23, 2025
<br />Yr.):::;:.
<br />O
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