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<br />STATE OF NEBRASKA
<br />,!,A in2 5d1411177A'(1Jom
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<br />WHEN THIS COPY CARRIES: THE RAISED SEAL OF STATE OF NEBRASKA, tT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY 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 />ffi
<br />DATE OP ISSUANCE'°':
<br />4/9/2025•.
<br />UNCOLN, NEBRASKA
<br />202602471
<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 />103ECEDENT'S-NA►ME (Firtst :;: Middle, Last, Suffix)
<br />pale LeRciY''Skow
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Central City,:Pebraska
<br />7. SOCIAL SECURiT
<br />506-384310:
<br />NUMBER.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />89
<br />eb. FACIUTY-NAME (If not Institution, give street and number)
<br />2320 N<Howard Avenue
<br />5c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d: STREET AND NUMBER'F.;
<br />2320 N Howard Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />11 FATHER'S -NAME (Firth, `' Middle, Last, Suffix)
<br />/Gilt eft Maurice Skow
<br />13. EVER IN`U.S. ARMED FORCES? Giyadates of service If Yes.
<br />(Yes, Nra,or Unk.) No
<br />15.'METHODOF DISPOSITION:::
<br />( Burial 0 Donation :.<
<br />Cr11matIon °Bntombersht
<br />❑Removal ❑ Other (Specify)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />25 04.243::::
<br />3. DATE OF DEA
<br />March 6, 2C
<br />O. DATEOFBIRTH (Ma, Day, Yr.)
<br />Deoettiber 27, .1935
<br />So. PLACE OF DEATH
<br />HOSPITAL, 0 Inpattettt OTHER 0 Nursing Home/LTC
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA T' .': 0 Other (SPRINT)
<br />5d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island .
<br />❑SriClfat+
<br />AA 9f. ZIP CODE 9q INSIDE 4tTY.l.t
<br />68803 ® AIR
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) ',wife, give maiden name
<br />Shirley Marie Keiper
<br />14a. INFORMANT -NAME
<br />16a EMBALMER-SIGNARIRE
<br />Not Embalmed
<br />9a: PT. NO.
<br />12. MOTHER'S -NAME (First, Middle, Malden
<br />Ada Mae Campbell
<br />Shirley Marie Skow
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION:
<br />Central Nebraska Cremation Services
<br />17*.:FUNERA..HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />AR Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska
<br />'Ob. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1g. PART I. Entwl the chain of events. -diseases, Injuries, or complications -that directly caused the death. DO NOT enter tenpins, events such as cardiac arrest,
<br />respiratory Fdr.st, or ventricular nbrilation without showing the etiology. Da NOT ABBREVIATE. Enter only, one cause on a line. Add additional lines M necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIMTE CAUSE Ins? a)Recurrent Bladder Cancer resistant to treatment with muscle invasion
<br />ateram car ;matron routine
<br />in fleet.) ...
<br />Sequentially rest conditions, M
<br />antiI..adlnp:to'ifl crud :petretA:
<br />•on lln� a:
<br />Ellerth iUkq}p,Rt.Y1N!t#:t3Atieti
<br />(disease or Injury that initiated
<br />Me events resulting in Meth)
<br />LOOT
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) History bladder cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />'Mk PART IL OTHER SIGNIFfCCANT CONDITIONS -Conditions contributing to the death but not resulting in: the ma:1ring cause given in PART 1.
<br />Pneumonia 2/26 Chronic Obstructive Pulmonary Disease, Nephrolithiasis, MALT lymphoma in 2001 anal 2006, Hypothyroidism,
<br />Chronic respiratory failure with hypoxia, Coronary artery disease sip stent 2017, Hypertension
<br />20 tF:FEMJALE
<br />Not pfynsntwIthin past yea:
<br />Pryjnentetams'otwsth
<br />Not pregnant, but pregnant wahtn 42 days of death
<br />Not pre9tNnt, but pragnant48 days to 1 year before death
<br />ilnkndudiirpnprtara wahin U r.put your
<br />na DAYS
<br />OF JURY#Mb :Dly; Yr.)
<br />21a. MANNER OF DEATH
<br />Natural Q-Nondhide
<br />❑ Accident 0 Pending investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />rTh. IF TRANSPORTATION INJURY
<br />pomwatindor
<br />.� Paaetinger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP
<br />Spouse.
<br />tea DATE(M0.,ltay,`04'
<br />March 11, 2625i
<br />onset to death'
<br />19. WAS MEDIOAI.ENAMINE(T.:
<br />OR CORONER CONTACTED?
<br />O YES l N0
<br />21c. WAS AN AUTOPSY PERPOIOAELIT
<br />❑ YES sat
<br />21d. WERE AUTOPSY
<br />TO COMPLETE CA
<br />❑ YES
<br />22c. PLACE OF INJURY -At home, faun, street factory, office bultdlno, construction
<br />22d.INJURY AT WORK?
<br />QYEs.ONO
<br />22i *OCATION OF INJURY STREETS NUMBER, APT.NO. CITY/TOWN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Y .)
<br />March 6 2025
<br />23b. DATE SIGNED{R►o., bay, Yr.)
<br />Mart M 27 2025..
<br />23c, TIME OF DEATH
<br />01:03 PM
<br />TB the beif of my kttierriedge, deeesh occurred at the time, date and place
<br />Brig dui t. the Cwlpiis) stated. (signature and 711M)
<br />Kimberly A. Mickels, MD
<br />is
<br />r1
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24a PRONOUNCED DEAD (Mo., Day, Yr.)
<br />124e. an ti. ltgla. of examination andlor investigation, in my.opbaon AO* 44600'i
<br />"the tknr date and place and dos to tM couseis) xlalsa t$lgN* at.1 Wk) :.
<br />24b. TIME of DEATH
<br />24d. TIME PRO
<br />0
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 25a. HAS ORGAN OR TISSUE DONATION: BEEN CONSIDERED?
<br />j YES ❑ i+NO ❑ PROBABLY El UNKNOWN El YES 27 NAME, T)TLE ANO ADrSS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />Bib. WAS CONSENTGI
<br />Not Applcable If 26a Is NO
<br />28b. DATE FILED BY RE
<br />March 27, 2025
<br />AV
<br />t'
<br />NT
<br />
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