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WHEN < THIS ` COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />20180'784
<br />TANL _.,�_;`Eroll
<br />R
<br />TANLEYc .COOPER
<br />DATE OFIISSUANCE
<br />8/10/2018
<br />LINCOLN, NEBRASKA
<br />AS ISTA t° STATE REGISTRAR
<br />RUSSELL FOSLER DEPARTMENT HEALTH AND
<br />INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Roger Lee McShannon
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 31, 2018
<br />4. CITY ANO STATE OR TERRITORY, OR FORE:GN COUNTRY OF BIRTH 158. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH. (Ho.,.Day, Yr.)
<br />Bloomfield; Nebraska 1 (Yrs.)
<br />76
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 3, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-7576 ,_.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ©Inpatient OTHER 0 Nursing Home/LTC ,.. ❑ Hospice Facility
<br />8b, FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />809 S. Vine St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced' 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sharon Kay Wegner
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John McShannon
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Minnie Stark
<br />13. EVER IN U.S.: ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No :
<br />14a. INFORMANT -NAME
<br />Sharon Kay McShannon ;
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />® Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L. Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />August 6, 2018
<br />❑ Cremation 0 Entombment
<br />❑.Removal : ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples
<br />_-•_ _�
<br />18. PART I. Enter the chain of events --diseases, injuries, or compiications-that directly caused the death. DO NOT enter terminaievents such as cardiac arrest,
<br />APPROXIMATE. INTERVAL
<br />respiratory arrest, Of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a)Lung Cancer, Metastatic
<br />disease or condition resulting
<br />in
<br />onset to death
<br />Months
<br />death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, if < b)
<br />any, kedrng to the- cause 11sten
<br />on lime a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury -that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to death
<br />18. PART II. 0 7 4ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />20. IF, FEMALE:
<br />0 Not pregnane within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />0 g
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />❑
<br />❑
<br />0
<br />Not pregnant,
<br />Not pregnant,
<br />Unknown if pregnant
<br />but pregnant within 42 days of death
<br />but pregnant 43 days to 1 year before death
<br />within the past year
<br />0ouermine
<br />❑ Suicide Ctd not De determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK? :.
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER 'P
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 31. 2018
<br />To be completed by`
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY`
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 2, 2018
<br />23c. TIME OF DEATH
<br />07:45 PM
<br />24c. (PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Travis S. Hageman, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USECONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE ,,,r,r�''
<br />'� """' 4_.--------- -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />August 7, 2018
<br />
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