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<br />STATE OF NEBRASKA
<br />ry24514'It%ti11iJFSa....•!.atrlrn111� °s..
<br />Vii!H I THIS COPYCARRIE5 THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA>TRUE'COPI+ .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 />DATE OF ISSUANCE
<br />1/14/2026
<br />LINCOLN, NEBRASKA
<br />2U26U261 3
<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 pEATH
<br />14EC15DENT.. 44AMEAlarec. Middle, Last, Suffix)
<br />Pt itrlc)a Jear1 ":GOIka
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />LaWreflce, Nebraska...
<br />T.`SOCIAL, SECURITY NUMB
<br />50541 293t
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />a
<br />i
<br />Ob. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health: St, Francis
<br />Sc. CITY OR::TOWN OF± DEAT H. (Include Zip Code]
<br />Grend.tslend 68803'
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />Ob.000NTY
<br />Hall
<br />It#'STREE'I'#NWNdfAIgIti :.
<br />1757 S Ar#fur Street
<br />10e. MARITAL STATUS AT TIME OF DEATH ® Married. 0 Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />tt FATHER`S-NAME (FDA,' Middle, Last Suffix)
<br />* Hubert 4std :.
<br />13. EVER IN U.S. ARMED'FORCES?
<br />quo, No, or unit.) No
<br />IS.. METHOD QF Qtii8tPOM'l1QIl
<br />®hula W Donamc(t;:,
<br />❑ Otinnerron u Entombment
<br />❑ Removal ❑ Other (Specify)
<br />fib. UNDER 1 YEA"-
<br />MOS.
<br />DAYS
<br />2, SEX
<br />Female
<br />6e. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT)t..
<br />January 8, 2o2p•::
<br />S. DATE OF RIM(Ma., Day; W;)
<br />Sa. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC
<br />® ER/Outpatient 0 Decedent's Hot
<br />❑ DOA ❑ other (Specify)
<br />Id. COUNTY OF DEATH
<br />Hall
<br />tic. CITY OR TOWN
<br />Grand Island
<br />OIL APT. NO.
<br />ff. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First Middle, Last, Suffix) N wife, giro maiden new
<br />Robert J Golka
<br />12. MOTHER'S -NAME (First, Middle, Malden Surnam s)
<br />Louise Brockman/
<br />14a. INFORMANT -NAME
<br />Robert J Golka
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Patricia R. Curran
<br />tad. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />$ERAL HOME N GEAND MAILING ADDRESS (Strict, City or Town, State)
<br />Cran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1092
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examples)
<br />tie PART L later the plain of added ,Alsgees. Injuries, or compacaJlons-that tinselly caused the death. DO NOT enter terminal events such as cardes arrest,
<br />majNatary arrest. or ventneuter nhdiitlen without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on line. Add additional lines if nsceoary.
<br />IMMEDIATE CAUSE: /
<br />FMewu1ye r ;;; ;a) Cardiac Arrest
<br />Iteesea or on Iantesurtins'`''
<br />Sequentially as conditions, a
<br />fey, iW filtitp tho6Hiss s!tl:d i
<br />ailarws
<br />S asar/Mjgl0E6.*I0CA0401
<br />(geese* or Mims that enMleled
<br />Me evens resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Diastolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. mat a OTHER SIGNIFICANT CONDITIONS.Condltiots contributing to the death but not moulting In the underlying cause given In PART I.
<br />Atrial Fit> letiorr s/p AV Node ablation/ PacemakerM/atchmen, Tubular Adenoma colon polyps, Generalized Osteoarthrltis of
<br />thick and Spine, Fibromysigia, H/0 Pulmonary Embolism with pulmonary Infarction, Hypertension, Diabetes, Lymphedeme,
<br />rO tP "MALE
<br />o Not pm tIe MNdiitl Wet yea`::
<br />❑ >Ratlni.afdeasl
<br />Not p gnsnnR bill pragnaa within 42 days of death
<br />❑ Ns p
<br />r
<br />o
<br />v
<br />e
<br />s,
<br />but Mealwit 42 days to 1 year bsfors death
<br />❑ WI$Qst>tapillpe,wvrNflHY: MPeayear
<br />VA PATE OF INJURY Milo
<br />22d. INJURY AT WORK?
<br />[YES: C3No
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Holniclds
<br />❑ Accident 0 Pending lnvadganon
<br />❑ suicide 0 Could not be dasnnlsd
<br />22b.11ME OF INJURY
<br />21b IFTRANSPORTATION INJURY
<br /><p Dlivgpereter
<br />.::❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIDNakile'DECEDENT
<br />Spouse
<br />1so. DATE (M5,ogtrtr{i) N
<br />January 9, 253`
<br />r
<br />$ATE
<br />anaalTORIN tlt
<br />9 Years
<br />oneat to
<br />19. WAS MEDIC LAXANSNII'It. .
<br />OR CORONER DORiA ._ ..
<br />RYee
<br />21c. WAS ANAL/ fl
<br />❑ yes . I
<br />21d. WERE MOONYF
<br />TA COMPUTED*
<br />DYES ©ice
<br />22c. PLACE OF INJURY -At hone, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />tlFINJURY .':STREET & NUMBER, APT.NO. CITY/TOWN STATE
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />I. a January 5 2026
<br />y 23b DATE SIGNED (Mo., Day, TO23c. TIME OF DEATH
<br />�Jartiulljry 1 2026 10.14 AM
<br />2241, To dill bast df'my %i6Miedge, dash occurred et the time, date and place
<br />end:drNt ie that lue$s) steed. (Signature and Me) Y.
<br />Kimberly A. Mickels, MD
<br />24, DID:TORACCO USE 0011TRIBUTE TO THE DEATH? \ 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED?
<br />YES NO PROBABLY ❑ UNKNOWN ❑ YES I J NO
<br />V. BE, lt'!L ADD ESS OF CERTRER (Type or Print
<br />Kim(kkly A Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. THE OF D
<br />24d. TIME
<br />24e•:9n tea be ti of examination and/or Investigation, In my opletmi 4. p do¢illy
<br />ten timq data and place and don to the camels) slated. (signature and
<br />tab. WAS CONSENT 00411104
<br />Not Applicable If 2p is NO (Y.S$
<br />26b.,6ATE FILED sr RlaIS111f6t_j b.'.,
<br />January 13, 2026
<br />
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