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<br />11 STATE OF NEBRASKA )
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<br />14P4MEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF ME 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 />I
<br />S.
<br />i
<br />DATE OP ISUINC ' I
<br />4127/2O26<: :<:
<br />UNCOLN, NEBRASKA
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<br />202605302
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<br />SARAH 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 />l CEBENTS.NAME" (Ftr's), z. Middle, Last, Suffix)
<br />4. CITY AND STATE OR' TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ROSSIO:lowa -
<br />T SOCCAti. SECURity NUMBER:
<br />484: 38 O698
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />91.
<br />lb. FACILITY -NAME (H not Institution, give street and number)
<br />Grand Island Country House, L.L.C.
<br />11CITY OR TOWN fJF 11NATli(nciode Zip Code)
<br />Grand; Island :>68803:`
<br />9a. RESIDENCE -STATE
<br />ct
<br />9d STREET AND NUMBER
<br />254;I.Lakewood Drive
<br />9b.000NTY
<br />Hall
<br />10a, MARITAL ST TUS AT TIME OF DEATH ®Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11 :FATHER'S NAME (First,•<: ::..
<br />Sanford : Reed
<br />13 EVERIN U 8. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes
<br />15ittETHODOF DISPOSfTli N
<br />© Burial 0Oonation
<br />Ctineepn Entombment
<br />❑ Removal Other (Specify)
<br />, Last, Suffix)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL ❑ itlpatent
<br />❑ ER/Outpatient
<br />❑ROA
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />I, HOURS
<br />MINS.
<br />3. DATE OF DEATHo4. O
<br />April-13. 2026:
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 13,1 p
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedents Home
<br />❑"tg/l�Mq Iri
<br />f
<br />-ill Other (SPaciY1ASSISTEDLIVI
<br />9d. COUNTY OF DEATH
<br />Hall
<br />tier. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden neins,
<br />Precious
<br />14a. INFORMANT -NAME
<br />Precious Reed
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Baylee Jolene Clifton
<br />Hofrichter ...
<br />12,;MOTHER141AME (First,
<br />Hattie Sylvester
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1T*, FUNERALHOME NAMEAMD MAIUNG ADDRESS (Street, City or Town, Stale)
<br />:/ki)f3Y.FUfilirliVNottio, 1'123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1604
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />12. PART I. Enter the chain of events- alsgsses, injuries, or complicatlens.Wat directly caused as .teeth. DO NOT sow terminal events such r cardiac arrest,
<br />reepMslmy arrest, or venOlcuMAlediallsn without showing the etiology. DO NOT ABBREVIATE. Enter only one curse on a.ine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />RIDIEWut'rsCAUSE t a?:respiratory failure
<br />. i sic Of coneetaonjl fore*
<br />in dealk)
<br />6equendaly Nat conditions, If
<br />arurt:IMdingtp1Mcau seam
<br />1S . an.lfie
<br />I EntertMiUNDERLYINGCAUIS
<br />' (disease or Maury that Initiated
<br />the *vents resuaMg M death)
<br />LAST
<br />i
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />l6 PARTI,GT.ER BIGNINCAHT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in P
<br />.congestive heart'fe4ure, atrial fibrillation, history of lymphoma, chronic obstructive pulmonary, coronary artery disease,
<br />disease
<br />20 IF flotFEMALE
<br />yregnant MdlMndaetyer: I
<br />Pnpnaneattue.at tarath ` ::`
<br />Not pri.nani, bat ptegnult Within u days of death
<br />0 Not pregnant, but pregnant a days to 1 year before death
<br />:thuarovrdiftuegnlnrvdehilh pestysat
<br />22a DALE OF INJURY
<br />(Mo , Daay; Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES.::0 NQ:::. :<
<br />21a. MANNER OF DEATH •
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />ElSuicide ElCould not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Drivalop►ratar
<br />Passenger
<br />22c. PLACE OF INJURY -At home,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f'LOCATION OFINJURY STREETSNUMBER, APT.NO. CITY/TOWN
<br />`RT
<br />i
<br />.2
<br />I
<br />29a. D.ITE OP DEATH (Mo., Day, Yr.)
<br />April 13 2026
<br />23b DATE SIGNED (Mo , Day, Yr.)
<br />AD111:14 20
<br />23c. TIME OF DEATH
<br />08:00 PM
<br />aid Teal bet of mykfu M edge, death occurred at the time, date and place
<br />OH the astree(s) stated. (Signature and Title)
<br />Isaac J. Berg, MD
<br />14b. RELATIONSHIP TO diction
<br />Spouse
<br />is DATE (Mo., I
<br />April 14, 2028
<br />IItAtE
<br />onset to de Ih
<br />onset to
<br />onset to dos"
<br />ART I.
<br />19. WAS ME
<br />OR CORONER CONY
<br />❑ YES rN10RFO:a;a:.
<br />21c. WAS AN AUTOPSY EERl
<br />❑YES e?ND
<br />❑ Pedestrian Other ( pecilyl
<br />21d. WERE AUTOPSY:FINAVLE
<br />TO COMPLETE CAUSE OF O55A114?
<br />❑ YES i[] WA'
<br />rm; street, factory, office building, construction site, etc. (100010)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day,Yr.)
<br />24c,.PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e. On tie basis of examination and/or Investigation, M my opinion death *ccUitr ait
<br />the time; date and place and due to the causes) stated. (Signature and Tide)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />al YES NO la PROBABLY ❑ UNKNOWN
<br />Zr.NAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg`MD, 729 North Custer Avenue, PO Box 2339, Grand Island,ebraska, 68803
<br />26i. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES RI NO
<br />26b. WAS CONSENT GRANTED?";'. ".
<br />Not Applicable 126a Is NO ❑
<br />28b. DATE FILED BY REGISTRAR (f:D:a
<br />April 15, 2026
<br />
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