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<br />(______ ISTATE OF NEBRASKA_ _
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<br />WHEN THIS COPY CARRIES THERAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A:"RuE 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 />ti
<br />►ATE OF ISSLUANCE •
<br />6123/2025
<br />LINCOLN, NEBRASKA
<br />1. IECLOEN"r'S.NAME(Flreitq: Middle, Last, Suffix)
<br />l Bveda Mae Rathman
<br />202605280:
<br />4t.. 0,344tiztlkot
<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 />4, CITY AND STATE OR TEitRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doni40an, Nebraska:.:..
<br />T SOCIAL SECURITY NUMBER
<br />055-52. 267
<br />6b FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Squtie Care.;Center
<br />8G, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island.. 68803 :
<br />Si. RESIDENCE -STATE
<br />Nebraska
<br />9b.000NTY
<br />Hall
<br />Sd"STeeET AND NUMBER
<br />3119 West Faidley Avenue
<br />10a. MAR AL STATUS AT TIME OF DEATH 0 Married ❑ Nevor Married
<br />❑ Married, but separated E] Widowed 0 Divorced ❑Unknown
<br />11 FATKER'S NAME (Pleat :;..Middle (Last, Suffix)
<br />Law/Ronde /; Kroeger
<br />13t EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />Yes, No, or Unit.) No
<br />13: METH OD OF nie ctat7(ON
<br />Syrial ❑ Donation ::
<br />Ctumatjon ( Entombment
<br />❑ Removal ❑ Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yes.)
<br />85:::
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL ❑:Inpatient
<br />0 ER/Ou patient
<br />DOA.
<br />9c. CITY OR TOWN
<br />Grand: Island
<br />HOURS
<br />MINS.
<br />3. DATE OFDEA11.141o.<: Day, S!r.
<br />June 11,,2025 :.::.:
<br />e. DATE OF BIRTH (Ma D
<br />August 9, 199:
<br />OTHER ® Nursing Horns/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH'
<br />Hall
<br />Be, APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai
<br />12, MOTHER'S -NAME (First, Middle,
<br />Grace Schultz
<br />14a. INFORMANT -NAME
<br />Darla Rathman Treacy
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Shridan
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />1Ta.FUNERAL HOME NAME,AND MA LING ADDRESS (Street, City or Town, State)
<br />Alt Faiths PIir era) Home; 292i) S. Locust Street, Grand Island Nebjaska
<br />18b: LICENSE NO.
<br />1439
<br />CITY / TOWN
<br />Doniphan
<br />CAUSE OF DEATH 'See instructions and examples)
<br />Maiden Stlmame).'
<br />la. PART I. Enter the Chain Of evsn4-;diseases, Injuries, or complications4hat directly caused the death. DO NOTTenter terminal .yens such as cardiac arrest,
<br />maintain/ arrest, or ventricular fbr Nation without showing the etiology. DO NOT ABBREVIATE,: Enter only one cause on aline, Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />hl DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentallyjist cohdlgons.lf... b)
<br />wieedlnytoti» ciptaa estert';
<br />Error the UNDERLYING CAUSE;"C)
<br />(doss or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />1.
<br />E TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I..PAR'I'II OTf1ERTSIGN)FICANTCONDITIONSConditions contributing to the death but not resulting In the underlying cause given in P
<br />Dementia, Obstructive Steep Apnea, Hypertension
<br />Rt► lF FIMALE
<br />Nat:pregnaat wlthl*t pant year.
<br />❑r Pregnant at line of death
<br />LJ Not pregnant, but pregnant within 42 days of death
<br />0 Nat pregnant, but pregnant 43 days tot year before death
<br />❑;Ui*nowlrbfa}f n0. wi6llirthl ::past year
<br />URY ( :O;y, Yr.)
<br />22d. INJURY AT WORK?
<br />NO.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Horlieidl
<br />❑ Accident ❑ Pending:. Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2fy.y IF TRANSPORTATION INJURY
<br />Drlver/Oparetor
<br />Paaserpar
<br />0 Pedestrian
<br />0 Other (apecify)
<br />14b. RELATIONS
<br />Daughter
<br />16c. DATE (Mo.,
<br />June 17, 2
<br />Faicltity.
<br />iE.
<br />N abre!kal
<br />17b .. CrDtt
<br />onset to
<br />Hours
<br />onset to death
<br />onset to
<br />ART I. 19. WAS MEDICAL .
<br />OR CORONER OQNTA
<br />YES
<br />21c. WAS AN AUTOPSY PERFoi
<br />❑ YES
<br />21d. WERE AU
<br />TO COMPLE
<br />0 YES
<br />22c. PLACE OF'INJURY At home,:farm, street; factory, office buiidinb, construction snit;
<br />22e. DESCRIBE HOW -INJURY OCCURRED
<br />22r:LOCATIONOFINJIfRY REETI. NUMBER APT NO CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June11 2025
<br />1°
<br />25 DS? Tgeagp0 f 5 COKt71#EuTE TO THE DEATH?
<br />I YES [� PRULIABLY 0 UNKNOWN
<br />Katie L Peters Settle, APRN
<br />23i* DATE SIGNED:(Mo., Day, Yr.) I 23c. TIME OF DEATH
<br />June 112tf2 01:27 AM
<br />$�d Talhs.best of my knowledge, death occurred at the time, date and place
<br />era this 1e the eaiieels) etatod. (Signature end T is)
<br />26a. HAS ORGA
<br />❑ YES
<br />Jr
<br />$ to
<br />a
<br />OR .e
<br />i'7
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Roc PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e,.On lhe.bflls Cl examination and/or investlgation, in my opinion doe
<br />• the time;'date and place and due to the caveats) stated. (Signature#
<br />AT1ON BEEN CONSIDERED?
<br />AREc'17f,E` Aots061) OF CERTIFIER (Type or Print)
<br />Katie L Peters Settje, APRN, 416 N Diers Ave, Grand Island, Nebraska, 68803
<br />ass, aEGISTRAR'S S GNAT..URE
<br />ak--12. 1 �6•� re e rr a�
<br />26b. WAS CONSENT GRANTS
<br />Not Applicable If 26 la s NO
<br />28b. DATE FILED BY REGIS'
<br />June 18, 2025
<br />
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