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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRI THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE'A>TRUE COPYOF 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 />202602611
<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 />' `ologoE.Nis-NArIIE.iififst« Middle, Last, Suffix)
<br />4 CI Y ANtOtSTAYEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />:E rr! 77otESSIO :
<br />. SECUNITY NURSESi
<br />lb. FACILITY -NAME (M not InsfKution, give street and number)
<br />.362.fE Artktu :St:M,
<br />tic, CITY OR TOWN OF DEATYI:;tinclude ZIp Code)
<br />Gland tatand •688t3'
<br />!s. RESIDENCE -STATE
<br />1ebeaaka..
<br />tt BTREET AID NUMeE
<br />Sb. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />ga. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Morriedl
<br />I] torrid, but yPv d ❑Widowed 0 Divorced 0 Unknown
<br />0;#* tEkihNASS (Ff ;lil, ": ;> Middle, Last, Suffix)
<br />Pete..:..::Tasictl
<br />13. EVER IN U.s. ARMED FORCES?
<br />*Yes, NO, or Unk.) NO •
<br />IL:METHOD OF DISPOSniON
<br />Ilewtai DDaf<..
<br />:Q DEntomiwnunt
<br />❑ Removal ❑ Other (SpsGfy)
<br />75.
<br />2. SEX
<br />Male
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH,'
<br />HOSPITAL El inpatient
<br />❑ ER/Outpadent
<br />❑ ooA
<br />Sc. CITY OR TOWN
<br />Grand Island. .
<br />3. DATE OF
<br />Found M; fdry
<br />R S. PATE OF al!RAI IMo•..Day,Ynl
<br />February t
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent* Horns
<br />❑ Other (Specify)
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Lynette
<br />Krull
<br />IL -MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Daisy Zvezdich
<br />14e. INFORMANT -NAME
<br />Lynette Tasich
<br />16s. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />1:eb. LICENSE NO.
<br />1439
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />111"#UNEIt IU:HOii NAME'AND MAILING ADDRESS (Street, City or Town, State)
<br />A I ithif can raI; HOWip, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />IL PART igniter the chain of rents. - irtemes, requites, or compaeationsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />eepk4tery emselt p[ gntrkeW fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a HnN..Add addklonsl lines If necessary.
<br />IMMEDIATE CAUSE:
<br />.:ENAIENATECAUlE 1nN •
<br />•,.; :, 1i) Unknown Natural Causes
<br />4N 0041tt nlitit:ai ;iw414
<br />in doled DUE TO, OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />Enter B»' IlifeRLWlf#CA "` C)
<br />(dleeaee or henry that Initiated
<br />evens waulline In ) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST M)
<br />IL PARTI OT#IEIs5tGNthCANTCONWTIONS-Conditions contributing to the death but not resulting hi the Underlying cause given in PART I.
<br />Hypertension /
<br />szclf FEMA1 ;; ..
<br />o Motpnaq►lteiTrwYFp;ywi
<br />] Prlyliepl1*115 iftdseet
<br />...r❑ Net pmgnaat, DIa pregnant aiUb 42 days of death
<br />} ©., prianud, Downie t 4a days tot year before death
<br />. 1 wn:Ifpnp It R5*;wutyear
<br />AK DATE
<br />ltilIt,E Y(Ittii(,,Piy,Yr.)
<br />22d. INJURY AT WORK?
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide 1
<br />❑ Accident 0 Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATK
<br />Spouse
<br />lea DATE
<br />_ March 13,
<br />most
<br />IL WAS
<br />OR
<br />® YES I
<br />21c. WAS AN AUTOPSY
<br />_ ❑ YES RI
<br />21d WERE AUTOPSY PokAmoi AVAILABLE
<br />TO COMPLETE CAUSE DI< T117.
<br />❑ YES CI
<br />22c. PLACE OF INJURY -At home,farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />1f'LQC)1TIt GF INJUIIXr..:: BEET E NUMBER, APT.NO.
<br />RF
<br />II
<br />I
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN:....
<br />2E04AAT IGNE0 too., Day, Yr.) 23c. TIME OF DEATH
<br />2aii,,T¢ AIMt Ornettertmledge, death occuned at the time, date and place
<br />uuMto thl:cl rNN stated. (Signature and Tale)
<br />iFir-ID TWACCO. CONTRIBUTE TO THE DEATH?
<br />Q YES CJ:NO PROBABLY (0 UNKNOWN
<br />2'F NAME*. AID ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26a. HAS ORGAN ORTISSUE A
<br />❑ YES r
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 14, 2026
<br />24b. TIME OF DEATH
<br />Unknown
<br />?AL PRONOUNCED DEAD (Mo., Day. Yr.)
<br />March 8, 2026
<br />24d. TIME PRONOUI.C�
<br />02;451
<br />24a. On the.bssie of examination and/or investigation, in my epeeist
<br />the time, date end place and due to the cause(s) stated. (Signature
<br />Martin Klein, Hall County Attorney
<br />TKiN BEEN CONSIDERED? 2eb. WAS CONSENT
<br />Not Applicable If 28a Is NO ©:
<br />28b. DATE FILED BY REGIS
<br />March 17, 2026
<br />
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