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<br />( STATE OF NEBRASKAvo
<br />%rrrJ,r1A.J1 k6tI1117iPt1IIJp`', .. '''
<br />+;IMrlrl1111111\�°
<br />!44JI1,11,11111Jt
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<br />WHEN rms. COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO.
<br />'E 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 yITAL IrCORDS
<br />E t)FIS•S / NOE
<br />4/1?/2026
<br />f DEcEDE.KpBtRA. ME`::(Fik3 Middle, Last, Suffix)
<br />202604450
<br />+4444/444
<br />SAB�AAH 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 />4.-i.`ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kea{na8r t !E braik
<br />SOCIAL SEcuRITY NitIgE R
<br />5506=68-1795:.;
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. FACIUTY.NAM€ Of not institution, give street and number)
<br />Eventide at Pra#ne Commons -Grand Island-3490 Ewoldt St
<br />t"/(iYORTOW CEDEAITH(lnclu
<br />Grandlsland 68803
<br />ga. RESIDENNCE+STATE
<br />Nebraska.. . >:
<br />it f. STREE t`AND.NUMBER'
<br />2510::Soth eii`:Dr
<br />Zip Code)
<br />9b.000NTY
<br />Hall
<br />1fle. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />❑ Married, but separated &l Widowed 0 Divorced 0 Unknown
<br />11. FATHER`S-NAME;: jFI str;:; Middle, Last, Suffix)
<br />Robert;; Ketti :;tevls Sr
<br />3. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) (1(D
<br />1S Mi 4400OF D SPOSiTION
<br />( :Muriel gl Dpnation
<br />-'❑ C►strtattort..] Eretar�larrwent .
<br />❑ Removal ❑ 0ther (Specifyt
<br />74
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />p DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH.(ly)a:, i3tiy Yr. )
<br />April 1, 2026
<br />6. DATE OF BIRTH Oa, Day,. Yr.)
<br />June 15,1951
<br />OTHER -❑ Nursing Hom&A.TC
<br />0 Decedent's Home
<br />® Oilier (SPeclfy)ASSIS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ile. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />14a. INFORMANT -NAME
<br />Glenn Perkins
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />12. MOTHER'S -NAME (First, Middle, Malden
<br />Marcia Rose Reger
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Anatomical Board
<br />va; Ft)NEI At. l OME'NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AtPaitlts Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />Mt PART I. Eniar'ttia
<br />w eareAteCaulatFlnld
<br />litiMOOrmithitrienatIng
<br />18b. LICENSE NO.
<br />1439
<br />CITY / TOWN
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<br />eta..dbaaeve, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />en without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a)Cardio-Pulmonary Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />w71ui6inetcWecusswawa ;:::.
<br />DUE
<br />Enter the UNDERLYING CJIW E C)
<br />(disease or Injury that Initiated
<br />OR AS A CONSEQUENCE OF:
<br />nain'1°04 DUE TO, OR AS A CONSEQUENCE OF: /
<br />d)
<br />1& PARF3iso mEFI. stonsFICANT CONDITIONS•Condltlons contributing to the death but not resulting in the underlying cause given in PART L
<br />Late Effects of Cerebrovaseular Accident, Hypertensive Heart Disease, Chronic KidneyDisease, Vascular Dementia /
<br />fj listPregt rttwttblPlsty !ir
<br />pnipnliat at Nm aid i >
<br />❑ Net but pregmneestaM day of loth
<br />::.:.O Not pngriarrt,.b..ut p1YYynant4$ days to 1 year before death
<br />fhfimJwYnwp te4d11nthepentyear
<br />21a. MANNER Of DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />BPassenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATION
<br />Son
<br />Fatally.::
<br />w TO pecEc€s
<br />1$. WAS MSD CAL:EXAMINeR'
<br />OR CORONER CONTACTED?
<br />❑S'...'® NO
<br />21c. WAS AN
<br />❑YES
<br />21d. WERE ABIOPSY
<br />TO COMPI.ETE CA
<br />\ ❑ YES Q No
<br />22fr't;OCATION:I
<br />Mty Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At honer, farm(street, factory, office building, construction**
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />231. DATE OF DEATH (Mo., Day, Yr.)
<br />ril 1 2026
<br />134 DATE SIGNED Into., Day, Yr.)
<br />Aoill 1 2026
<br />23c. TIME OF DEATH
<br />12:00 MIDNIGHT
<br />230, Td:lli : bostef .Y rimov ledge. death occurred at the time, date and place
<br />and'eiie WSW ceuse(atstated, (signature and Title)
<br />Heather M. Fago, MD
<br />S ISDTt'f:BACCOOU SE cot TRIBUTE TO THE DEATH?
<br />❑:NO.:::;Q"PROBABLY ] UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Dly, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24s. On the basis of examination and/or investigation, in my warm*
<br />the time, date and place and due to the commis) stated. (aigftatuta
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES . tia:NO
<br />27. NAMES 11TLE:AND'ADDRESS OF CERTIFIER (Type or Print
<br />Heather M. Fago, MD, 205 S Lincoln Ave Ste 101, York, Nebraska, 68467
<br />26b. WAS CONSENT GRAN
<br />Not Applicable If 26a Is NO
<br />28b. DATE FILED BY R
<br />April 7, 2026
<br />ODE
<br />
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