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<br />THIS COPYCARRIE;S THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />a A TRUE COPY: t P THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH' AND
<br />SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF UANC <
<br />8/24/2O26
<br />LINCOLN, NEBRASKA
<br />20260'5874 36,4
<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 />1 Deeepaipa hFAME (Fltsf : Middle, Last, Suffix)
<br />Mk he1Ie Renee Nelson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Joliet, Illinois::.
<br />7 SOCIAL SECUR4TY NUMBER
<br />508.62-7336:
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany: Square Care,Center
<br />Sc.•cm. OR TOWN OF DEATH.(Include Zip Code)
<br />Grand Island:68803
<br />9s. RESIDENCE -STATE
<br /><:: Nebraska
<br />!.. STREET AND NUMBER
<br />2317 N Sycamore...
<br />Ob. COUNTY
<br />Hall
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ['Widowed ❑ Divorced 0 Unknown
<br />11 FATHER`SNAME (First :':::: Middle, Last, Suffix)
<br />Donald Adler
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or (Mk.) No
<br />15r�MENOD OF DISPOSITION
<br />D Burial [ Donation:'
<br />Cremation .❑.Entombment
<br />❑ Removal ❑ Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />78
<br />Ba. PLACE OF ATH
<br />HOSPITAL ❑ inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. sax
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />:2610820
<br />3. DATE OF DEATH . illlo,:'Dliy, Yr)
<br />August 13, 2026
<br />8. DATE OF BIRTH IMo.rDay, Yr.)
<br />July 11, 1948:;:.
<br />OTHER ® Nursing Home/LTC 0'#1. 1pica FacNl{1r
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />90INS10E CITY Lippe
<br />p YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Victor Nelson
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Averil Schmidt
<br />14a. INFORMANT -NAME
<br />Victor Nelson
<br />18a. FUNERAL DIRECTOR SIGNATURE
<br />Baylee Jolene Clifton
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />INu FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />ARi f FuneralHome 1123 W. 2nd, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1604
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See inIttructions and examples)
<br />is. PART I. OW** chain Mamas. -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular flbril)etfoh without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />iMMEATE CAUSE:
<br />MMEDIAteoust taln l .... ) ReCtal cancer
<br />tlkaa».vrcondltlO resulting
<br />Sequentially NM conditions, if
<br />a:!qi M} Nfg to #M cause Mated
<br />on iins a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />i:: Enter rho tiNDEMLYIN�g¢ CAUSE . tiw
<br />IWan#w of injury thst lnmond
<br />the events resulting I death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b).
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART IL OTHER:SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />ptukinsons
<br />#P FEMLffA
<br />❑ Natpregaant vill#0 Wwt Y+ar
<br />❑ Pregr ant atsms up deatft
<br />:•tj Not pregnant, but pregnant wltMn 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />4:1 Unknown t praiRM t wllhin tit• past year
<br />225OiF": DATE INJURY (Mo.,: gay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />21a. MANNER OF -DEATH
<br />Natural El Homicide
<br />❑ Accident ❑ Pendinginvestigatlon
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DdverlOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP Tit) DECEDEN
<br />Spouse
<br />18c. DATE (Mo., Day, Yrt)
<br />August 14,2026'
<br />STATE
<br />Nebraska
<br />171x Zip
<br />681:
<br />19. WAS MEDICAi, EXAMINER.
<br />OR CORONER CONTACTED?
<br />❑ YES NO v.
<br />21c. WAS AN AUTOPSYPERFQRMEI
<br />❑Yes ®NO
<br />21d. WERE AUTOPSY FINDINGS AVMLIJI C
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ©flit.;::
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits,
<br />22e. DESCRIBE HQW INJURY OCCURRED
<br />22f LGCATtoN or:04./ua' STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 13, 2026
<br />CITY/TOWN
<br />230- DATE SIGNED{Mo., Day, Yr.)
<br />AugGat14 2026
<br />23a. TIME OF DEATH
<br />05:10 PM
<br />23d.To:t43(intt 41!ihy..laiowlsdge, death occurred at the time, date and place
<br />trod i ;to the::ciates(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25,,DID.TOBACCO USE t ON7RIBUTE TO THE DEATH?
<br />C YES ..... ®. NO ... ❑ PROBABLY UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED
<br />24e. On the basis of examination and/or investigation, in my Opinion tea b ocebrrid
<br />the time, date and place and due to the creels} stated. (Signature add Mint
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i 7 e
<br />27: N of 1;1'.f'LE AND ADD ESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MID, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska,68803
<br />lib. WAS CONSENT GRA
<br />Not Applicable if 28a Is NO
<br />28b. DATE FILED SY REGISTRAR;(Milo.,
<br />August 17, 2026
<br />
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