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<br />(/ STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BSA TRUE COPY OF me ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS O CE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />8/31 /2026
<br />LINCOLI)4 NEBRASKA
<br />202606506
<br />))/X4rt,A 0600idtAllkst-
<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' DEGE0ENT'S AIAME (First;;, Middle, Last, Suffix)
<br />Rachel L Hirtrikua
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Erancis,:l(ansaS:::
<br />T BoCIrAL SECU1UTY NUMBER
<br />506✓72-9244:
<br />lib. FACILITY -NAME (If not Institution, give street and number)
<br />1.3926::S 9I/0th Road
<br />1 CtTY OR TOYVN OF DEAi n (Include Zip Code)
<br />Prosser 68883
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />Ed.:STREET AND NUMBER
<br />13926 S 90th Road
<br />9b. COUNTY
<br />Hall
<br />ills. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />. 0 Married, but separated ['Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, ' Middle, Last, , Suffix)
<br />Robert M Bader
<br />13. EVER 1N`U.S.'AMIRBFORCES?
<br />(Yea, No, or Unk.) No
<br />16. METHOD OF DISPOSMON'
<br />❑ B1lrl& Q. condors :..
<br />to cr mauoil 4,1 Entombment
<br />0 Removai ❑ Other (Specify)
<br />6a. AGE - Last Birthday
<br />(Yrs.) /
<br />72
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />bc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL D inpettent
<br />❑ ER/outpatient
<br />[] DOA
<br />9c. CITY OR TOWN
<br />Prosser
<br />HOURS
<br />MINS.
<br />26!1.98
<br />3. DATE OF DEA114:04, Dap Vr.)
<br />August 24, 2026' :
<br />6. DATE OF BIRTH (Mo., Oily, Yr.)
<br />May 24, 1984
<br />OTHER rj Nursing Home&TC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />84. APT. NO.
<br />'9r. ZIP cope
<br />68883
<br />az D►S CrrY u6Al l3
<br />s
<br />Cr a `
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Myron Hinrikus/
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Delsie Olson
<br />14a. INFORMANT -NAME
<br />Myron Hinrikus
<br />16a. FUNERAL DIRECTOR SIGNATURE-.
<br />Baylee Jolene"Clifton
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Ira,>FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Apte1 Funeral Home,;505 N Bellevue, Hastings, Nebraska
<br />16b. LICENSE NO.
<br />1604
<br />CITY I TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a, PART I. Enter the chain of events- diseases, injuries, or compllcanone4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />Neykatory arrest, or venbicular nbrlllatlon without shoving the etiology. DO NOT ABBREVIATE. Enter only one alive on e. line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />BIS,tEINATE CAU$I8 khat
<br />tlbeawor candbion?Mulling
<br />In death)
<br />Sequentially Nat conditions, If
<br />a ay:;Nadldgto.YM coca WUd s:
<br />emi�te #:
<br />Jtlhter 004(RCERLY 3CAUS2
<br />::(dismiss or injury that Minted
<br />the events resulting in death)
<br />LAST
<br />16=-PART 11.0
<br />a)Ovarlan Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ER SIGNIFICANT CONDITIONSCondtlons contributing to the death but not muffing In the underlying cause given In P
<br />20 IF FEMALE:
<br />Net rignio utltdrl Pit yMr :
<br />Pmagdardattlntecrdalh
<br />❑ Not pregnant, but pregra'nt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before deal
<br />uktm..n1 pregia. WOhir tf!s.pest yea,/
<br />22a JURY DATE OF IN(M11., Qay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑;YES >:..❑No
<br />21a. MANNER OF DEATH
<br />El Natural CI Homicide
<br />❑ Accident ❑ Peadiny lnvutigotlon
<br />❑ BuiNde ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />CIDriver/Operator
<br />CIPassenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />141L-. RELATIONSI( t6 OEc
<br />Spouse
<br />lac. pnntE (MoT Day,Yr`;,)
<br />August 24, 2026
<br />• S't'ATE
<br />„Nebraska , .
<br />17b,t Cialiies.
<br />68901
<br />onset to dasth
<br />NT
<br />ART I. 19. WAS MEDICAIMAMINER.:..'
<br />OR CORONER.D6NTACTED?
<br />j] YES El N0
<br />21c. WAS AN AUTOPSY PER ARMED?
<br />1",-,1 YES ®NO
<br />21d..WERE AUTOPSY FIN
<br />TO COMPLETE CAUSE
<br />❑ YES ❑
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />226 LOCATION OF INJURY STREET IL NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />AVAILABLE
<br />DEATH?
<br />(SIt!ooty)
<br />B'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />/ August 24, 20,26
<br />73b. DATE SIGNEQ::(Mo., Day, Yr.)
<br />Auatt 242026
<br />23d•Tedte bind df ay kn owhsdge, death occurred at IM time, date and puce
<br />awd OS* tin dw1Ns) stated. (Signature and TIN)
<br />Gary L Settle, MD
<br />23c. TIME OF DEATH
<br />02:10 AM
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. T$Mi E-OF DEATH
<br />24d. TIME PRONOUNCED DEJt
<br />24e. t70 the basis of examination and/or Imaatiganon,Jn my opinion death occene l at
<br />the time, date and piece and due to the ause(s stated. (Signature eat llda..
<br />26rDID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES laNO 0 PROBABLY 0 UNKNOWN 0 YES RI NO
<br />.2T= NAM TITLE ANR ADDRESS OF CERTIFIER (Type or Print
<br />Gary L Settle, MD, 416 N Diers Ave, Grand Island, Nebraska, 68803
<br />❑
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES
<br />fi0
<br />26a. REGISTRAR'S SIGNATURE
<br />26b. DATE FILED BY REGISTRAR (Mo., Dayr,:Yr.):
<br />August 27, 2026
<br />1
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