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NAME, Tf1
<br />Isaac J.
<br />MC;7GMACCO.U.S ONTRIBUTE TO THE DEATH?
<br />d;YEsj.NO 0 PROBABLY 0 UNKNOWN'
<br />iD ADDRESS& CERTIFIER (Type or Print
<br />, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />.: _ _ _ ___ .,_:ill.......tri.:_.,.:.':.:i.1,rr::: °; ;�•:•: ': ,1 ,. �r:: ��%::
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<br />t7461):ICI:P.fft))>�s _;-_�.a.'/,45g9P1d6S
<br />COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />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 />OP ISSUANCE
<br />5I1912026
<br />LINCOLN NEBRASKA
<br />1 01«CEDEN1 S4NAM$;(FIr' Middle, Last, Suffix)
<br />EUgana• Carl ..:HariIpp
<br />4. CITY AND
<br />ST TB OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE Last Birthday
<br />SpBld3n N braska ':;�
<br />7. SOCIAL SECURiTY."NUMBER
<br />506-54-4381'
<br />lb. FACILITY -NAME (If not institution,
<br />CHI.Health St. Francis
<br />Sc C)1Y OR TOWN OFDEEATH (Inc/
<br />Grand tsiand 68803
<br />9a. RESIDENCE -STATE
<br />:::Nebraska
<br />lid. S;TREEtANDMJMBER < ;
<br />68:Ius 5ter Lake
<br />pipe atree4 end number)
<br />Zip Cods)
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT -TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑ Wtdowad 0 Divorced 0 Unknown
<br />11 MAfiiER'i NAME (Fkst;: Middle, Last, Suffix)
<br />Cart Harnapp
<br />13: EVER IN U.S. ARMED FORCES?•
<br />(Yes, No, or Unk.) YeS
<br />15. MEY;irta OF DISPOSITidti
<br />Buriai D4natton,
<br />titierboatiotiliu Etito,brnint
<br />Q Remove`(. ❑ Other (Specify)
<br />84
<br />202604637
<br />06.44141
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />8T�1TE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OFDEATH
<br />HOSPITAL tgl inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />HOURS
<br />MINS.
<br />3. DATE OM
<br />May 12, 20
<br />e. DATE or BIRTH
<br />OTHER 0 Nursing HomaILTC
<br />❑ Decadent', Nome
<br />❑11Other (Spy)
<br />ad. COUNTY OF )EATH
<br />Hall
<br />N..APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Betty Ha�c#edorn
<br />12. MOTHER'S -NAME (First, Middle, Mellen Surname)
<br />Gertrucl t Henry
<br />14a. INFORMANT -NAME
<br />Betty Harnapp
<br />19a. FUNERAL DIRECTOR S GNATURE
<br />Caleb J Alcorta
<br />15b: LICENSE NO.
<br />1607
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services / Gibbon
<br />lTo. FUNERAL. HI .ME NAMEAND MAIUNG ADDRESS (Street, Clty or Town, State)
<br />Aii l+aitits Funeral itortiie, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and -examples)
<br />L Etter the tMkf�w-.dbsasss, InNenCor complkNbns4hat directly caused the death. DO NOT enter terminal swats such as cardiac amest,
<br />t„or yeilbisular 16dMBon without shoving Me etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addkional Ilms if necossary.
<br />IMMEDUITE CAUSE:
<br />13) Respiratory failure
<br />rti Marini;
<br />>ori.9riatt. •
<br />t . JND `ilflo CAU$E
<br />Meese* of injury Chet InNiatod
<br />the swats resukk,g in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) congestive heart failure
<br />UE TO, OR1AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />a. PART IL OTHER IGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART].
<br />chronic kidney disease
<br />4kIF FEMALE
<br />Q Dat prottottotiOttltto pda# ye11r
<br />Prsgnegt ape 1*8*. of ttiatttig
<br />El sot ptegnent, WR pregnant within 42 days of death:El:Dat pregnant, but pregnant42 day, to yew before dameW1itltoisn irpagnsnt witi nths p�,yaaat
<br />1
<br />22a..1314TE OF INJURY (Mo ;nay, Yr.)
<br />22d. INJURY AT WORK? •
<br />❑YEs : Q0lo
<br />21a. MANNER OF DEATH
<br />ElNatural ElHomicide
<br />❑ Accident ❑ Pending Investigation
<br />ElSuicide❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑n Pedestrian
<br />/ Other (Specify)
<br />14b. RELA
<br />Spoj.se „'
<br />19e DATE
<br />May
<br />1**:U
<br />4
<br />on
<br />14
<br />19. WAS
<br />OR
<br />❑YEN
<br />21c. WAS AN AUTOPsy
<br />0 YES
<br />21d. WERE A
<br />TO COMPLO
<br />❑ YES
<br />22c. PLACE OF INJURYAthome, farm, street, factory, office bu�iding, constructlon.site;eta,`
<br />1
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />.:STREET & NUMBER, APT.NO. - CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 12, 2026
<br />, OATE SIGNED. (Mo., Day, Yr.)
<br />Mav;.1.3.:2028
<br />23e. TIME OF DEATH
<br />03:34 PM
<br />lad 1`o moot of nmy knowledge, dnth occurred at the time, date and place
<br />and dw to the auwN) **so. (Signahee and Tko)
<br />Isaac J. Berg, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. YeArte►otiv
<br />24d. TIME
<br />24e. On the basis of examination and/or Invesllga4an, in sty *Non
<br />the time, date and place and due to the causes) stated. (Sigma
<br />28a. HAS ORGAN OR TISSUE DONATION am CONSIDERED?
<br />❑YES b]NO
<br />21tb. WAS CONSENT
<br />Not Applicable B 28a is
<br />28b. DATE FILED BY
<br />May 18, 2026
<br />(Yrs )
<br />
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