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.. i..emSa STATE OF NEBRASKA u_ 0 v 5 b 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 RECORDS DATE OF ISSUANCE 5/31/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Monty Roger Kyhn 4. CITYANO. STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cotesfield, Nebraska 7. SOCIAL SECURITY NUMBER 505-44-3218 81e. FACILITY -NAME (if not Institution, give street and number) 20 St. James Place 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9.a. RESIDENCE-STATE _. Nebraska 9d. STREL• i Ara, { ""`fa 20 St. James Place 1Oa. MARITAL STATUS AT:TIME OF DEATH 2 Married ❑ Never Married Married, but separated;' ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Kyhn EVER IN U.S:::ARMED:FORCES? Give dates of service if Yes. (Yes, No, IN link.) Yes 10/13/1960-10/09/1962 15. METHOD OF:DISPOSITION ❑ Burial ❑ Donation 2 Cremation ❑Entombment q Removal ❑ Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska IMMEDIATE CAUSE (Final a) Aspiration Pneumonia disease or condition resulting !15 death);; egaertiauv fist ednditiots, if b)ACUte lschemic Stroke any, le td trip cause fisted on line Enter the UNDERLYING CAUSE (diseaSeofin)ury tllat midated: ;. the events resunmgan death ;; DUE TO, OR AS A CONSEQUENCE OF: G z O.IFFEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, glut pre gnant : 43 days to 1 year before death ❑ •Brutnotvn if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. }NJURYATWOR:K' 'I'Es ive COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO. OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) Hypertension 22b. TIME OF INJURY 2e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) May 25, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH May 26, 2017 10.08 AM d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) William Landis; MD 28a. REGISTRAR'S SIGNATURE 201801674 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last Birthday 5b. UNDEI (Yrs.) 80 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9t 14a. INFORMANT-NAME Kathryn Marie Kvhn 21a. MANNER OF DEATH 2 Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could het be deteltirtined CITY /TOWN NO ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 MOS. DAYS . CITY OR TOWN. Grand island` 1 YEAR STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 19e. APT. NO. lab. NAME OF SPOUSE (First, Middle, Last, Kathryn Marie Szwanek 2. SEX Male b. LICENSE NO. Gibbon CAUSE OF DEATHiSee instructions and examples) 5c. UNDER 1 DAY HOURS CITY / TOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 25. DtD TOBACCO? USECONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Cage M1NS. OTHER ❑ Nursing Home /LTC 2 Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEAT4 Hall 9f. ZIP CODE 68803 6. DATE OF BIRTH (Mo January 2, 1937 Suffix) If wife, give maiden name 1 ' 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ruby Gardner PART 1. Enter the chain of evaltits -- diseases, injuries, or complications -that directly caused the death. DO NOT entertermtnal events such as cardiac arrest, respiratory arrest, orventncular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ane cause on a line.' Add additional lines if necessary. IMMEDIATE CAUSE: 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) the time, date and place and due to the cause(s) stated. (Signature. and Title) 28b. DATE FILED BY REGISTRA May 26, 2017 24b. TIME OF DEATH 3. DATE OF DEATH (Mo., Day, Yr.) May 25, 2017 Day, Yr ❑ Hospice Facility 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT• Wife 16c. DATE (Mo., Day, Yr.) May 30, 2017 STATE Nebraska 17b. Eli/ Code 68801 onset trI dea 1 Month onset to death Years onset to deft APPROXIMATEINTERVAL onset to death 3 Weeks 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 2 NO 21c. WAS AN AUTOPSY PERFORMED? ;? ❑ YES I No 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH ?:: ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP CODE 8 w ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD H N u w z O 24e. On the basis of examination and /or investigation, in my opinion death occurred at a 2 K;:V 8° 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES' 0 NO