|
r
<br />1
<br />��`���Zlil,�4i'f$jiiir.�a:�4i?01�Sa.rAd52S1)37tttcfii2$t�iiii�iyS!S¢?%/.i..Nit.:4�t.(11i1t6y1�Qilyilii a 4i,���aliii�,iiSSte
<br />,cII _STATE OF NEBRASKA
<br />nvaa�r �tiv
<br />�YlttiiaBafias�s�._.
<br />?ytft147Afrfaas�*
<br />WHEN THIS COPY CARNES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OFTiYEORIGINAL 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 />6/29/2026
<br />LINCOLN, NEBRASKA
<br />(
<br />202605034
<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 />f DECEDENTS•NAME (First,:: Middle, Last, Suffix)
<br />Karen Gaye Terry'` /
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Madison, South Dakota
<br />T, SOtiAl SECURITY NUMBER
<br />503, 704.4682-
<br />5a. AGE • Last Birthday
<br />(Yr.)
<br />65
<br />8b. FACIUTY-NAME (N not Institution, give {treat and number)
<br />2020 N. Huston
<br />So, CITY OR 'TOWN OF DEATH (include Zlp Code)
<br />Grand Island68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ad€ sTREErANDNUMBER
<br />2020 N. Huston
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />if, FATHER'S -NAME (First, ": Middle, Last, Suffx) .,
<br />Jerome Determan.'
<br />13. EVER IN U.S. ARMEIWORCES? ,
<br />(Ys, No, or upk.) No.
<br />16. METHOD O) DISPOSITION
<br />0] Burial 0 Donatlan:
<br />® Cremation (Q Entombment
<br />0 Removal 0 Other (Specify)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ D►
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mq Day Yr)
<br />June 20, 2026
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 13. 1960
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />lie, APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑ E aplas Facie
<br />9g s1SlDE coy Loos'
<br />ffitios LC110
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Larry Terry
<br />14a. INFORMANT -NAME
<br />Lisa Sanders
<br />tee. FUNER/11, DIRECTOR SIGNATURE(
<br />Stacie L Cook
<br />MOTHER'S -NAME (First,\ Middle, Malden Surname)
<br />Kaye Olson
<br />18b. UCENSL° NO.
<br />1495 /
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Crematory Grand Island
<br />47e FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Ail Faiths Furi:erat Horne, 292,9 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples) --
<br />is. PART I. Enter the chain dimwits- -diseases, injuries, or complications4hat directly caused the death. DO NOT eider terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />48.118.14r agthgklorh teauitttg
<br />In death)
<br />sequentially list conditions, N
<br />any; healing to tin Pa* Iheett:
<br />Enter the UNDERLIIRIS CAUSE
<br />(disease or Injury that initiated
<br />Ms events resulting In death).
<br />LAST
<br />d)-
<br />8)Amyotrophic Lateral Sclerosis
<br />14b. RE(ATION.SHIP'TO1}ECEDENT
<br />Sister
<br />tee. DAT! (Nola . *
<br />June 24, 2026 '
<br />STATE
<br />Nebraska
<br />17b ZIp Code'.;;:
<br />68801'`
<br />APPROXIMATE INTERVAL
<br />*omit to dsatlt :l
<br />18 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />onset to death'::
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />it PARTII OTNER'SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Systemic Loads Erythematosis with CREST Syndrome
<br />* IF FEMAI,l:
<br />Net jlreolaid wtAto peat riar :
<br />❑ Prlrant it tlme of dseth
<br />❑ Not pregnant, but prepnent within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />un*nasm p pregnant withintM. past yur
<br />22*. DATE OFINJURY (Ma., Day. Yr.)
<br />22d. INJURY AT WORK?
<br />❑;YES ❑ ND
<br />21a. MANNER OF DEATH
<br />-® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />i
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to dsalh.,
<br />19. WAS MEDICAL;P.XAMINER.
<br />OR CORONER CONTACTED?
<br />❑ YES ® NQ
<br />21c. WAS AN AUTOPSY PER}ORMED?
<br />0 YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN_
<br />23e DATE OF DEATH (Mo., Day, Yr.)
<br />June 20 2026
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June '24.2026'
<br />23c. TIME OF DEATH
<br />06:31 PM
<br />dad, To Richest of may Imamsdp, death occurred at the time, date and (!lace
<br />and (WO the Ouse(*) stated. (Signature and Title) _. .
<br />Thomas F. Wemer, MD
<br />26, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />V. NAME, TITLE ANO ADDRESS OF CERTIFIER (Type or Print
<br />Thomas F. Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />(1y2 8 LZ
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCEDAD
<br />244. On the basis of examination and/or investigation, in my opinion death occurpp at
<br />the time, date and place and due to the cause(s) stated. (Signature and TIN)
<br />28. HA ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 50 NO
<br />26b. WAS -CONSENT GRANTED?'
<br />Not Applicable If 26a is NO ❑ YgS E] NO
<br />28b. DATE FILED BY REGISTRAR (Into., Day,
<br />June 24, 2026
<br />1
<br />
|