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STATE OF NEBRASKA ' ' . xt ,emsGwt. a C1 a. E 0 d WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECO RDS DATE OFISSUANCE 2/23/2017 LINCOLN, NEBRA. SKA 1. DECEDENTS -NAME (First, Middle, Last, Thomas Gardner Wyatt $. CITYAND STATE•ORL TERRITORY, OR FOREIGN COUNTRY OF BIRTH Topeka, Kansas 7. SOCIAL SECURITY NUMBER 510 -64 -9094 Suffix) 8b . FACILITY- NAME (If dot institution, give street and number) 4004 Sacramento Circle 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island it a. RE'SIDeNCe-e `Al' Nebraska 9d. STREET AND NUMBER 4004 Sacramento Circle 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Glenn T Wyatt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No of Unk.) N O 15. METHOD OF BiSPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska S nti Il list CORd e9ae. a y r :. the cause 1lstp ) d on Enter the UNDERLYING CAUSE (disease Or irtjurythat initiated the events resuhthg: death) DUE TO, OR AS A CONSEQUENCE OF: LAST i; d) 20. IF FEMALE: Not pregnamwlthin past year ❑ Pregnant at time Of deat ❑ Not pregnant, but pregnant within 42 days of death Net prie9nartt 1zut pre gnant 43 days to 1 year before death I ❑ unknown d Pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d : :( NJURY A T : WORK? i ❑ YES ] NO 16a. EMBALMER - SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C), 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. A o. t . DATE OF DEATH (Mo., Day, Yr.) February 10, 2017 z 23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH e February 10, 2017 12:26 AM a' 0 /23d. To the best of my knOwledge, death occurred at the time, date and place t snit due to the -. esetsj ofe'ed (R(Rive., (Rive., end Taal Ryan Ramaekers, MD 8 REGISTRAiR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 2017015E s 14a. INFORMANT -NAME Paula J Wyatt CITY /TOWN AGE - Last Birthday (Yrs.) 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient El ER/Outpatient ❑ DOA Cu. COUNTY St CITY OR TOWN Hall I M Grand Island 25. D1f) TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATIO ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers,MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 a j 9e. APT. NO. STANLEY S. DOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 16b. LICENSE NO CAUSE OF DEATH (See instructions and examples) 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall lob. NAME OF SPOUSE (First . Middle, Last, Suffix) If wife, give maiden name Paula J Sorensen ` 1< 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Mavis J Taylor CITY / TOWN Gibbon 9f. ZIP CODE 1 s. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventrieubr fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Esophageal Cancer Metastatic disease or condition resulting irt:deadrj liens if any, leading to tine: a. 8. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY Driver /Operator ❑.Passenger ❑ Pedestrian 0 Other (SpeciY) STATE 24a. DATE, SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. BEEN CONSIDERED? Covoi 3. DATE OF DEATH (Mo., Day, Yr.) February 10, 2017 6. DATE OF BIRTH (Mo., Day, Yr) June 27, 1956 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Oay, Yr.) February 11, 2017 A A onset to death 2 Years onset to deat onset to onset to ❑ YES ❑ NO 24b. TIME OF DEATH ❑ Hospice Facility STATE Nebraska 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUNCED DEAD !? E � �� w z 24e. On the basis of examination and /or investigation, in my opinion death occurred at g 5 P the time, date and place and due to the cause(s) stated. (Signature and Title) v ° 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR (M February 15, 2017 9g. INSIDE CITY LIMITS ® YES ❑ NO ZIP CODE Day, :Yr