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<br />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 />DATE ©F ISSUANCE 201906014
<br />1/1412019
<br />LINCOLN, NEBRASKA
<br />1.
<br />4
<br />RUSSELL FOSLER
<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 />DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Stephen Lawrence Gleason
<br />CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRT-:
<br />Norton, Kansas
<br />$ 7. SOCIAL SECURITY NUMBER
<br />`a
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<br />2
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<br />508-48-2076
<br />55. ACE - Last Birthday
<br />(YreJ
<br />78
<br />. FACILITY -NAME (If notktstitutlon, give street and number)
<br />Edgewood Vista Grand Island
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />25 Chantilly St.
<br />10a. MARITAL STAT./SAT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 5, 2019
<br />50. UNDER 1 YEAR 5c. UNDER 1 DA'r' 6. DATE OF BIRTH (Mo. Day.Yr:}..
<br />MOS. DAYS HOURS I MINS.
<br />February 5, 1940
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ 00A
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />0 Decedent's Home
<br />® Other
<br />(SPecifyl4SSISTED LIVING
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />9g. INSIDE env LIMITS
<br />tiaYES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sharon Ruth Bassett
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lawrence F Gleason
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Corinne Munson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or IW.) Yes : 05/28/1961-11/27/1961
<br />15. METHOD OF DISPOSITION
<br />®Burial '❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ; 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Sharon Ruth Gleason
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />10. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />January 11, 2019
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Hastings
<br />Sunset Memorial Gardens
<br />17a.:FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />STATE
<br />Nebraska
<br />17b.2;ip Code
<br />68801
<br />CAUSE OF DEATH jSe3 j,if:'u ticr,s arid tlysrnples)
<br />18. PART I. Enter ars chain of events- -diseases, injuries, or complications -hat directly caused the death. DO NOT enter terminal events such is cardiac arrest,
<br />iespiralo-y arrest, of Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause:: on a End._ Add additional fins If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Multi system Organ Failure
<br />disease or condition resulting
<br />In death)
<br />Sequentially list conditions, if
<br />any, kedina to the eau*. listed;
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />tdisease or Injury that Initiated:;.
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL:.
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Alzheimer's Dementia
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlons contributing to the death but not resulting In the underlying cause given In PART I.
<br />0. IF FEMALE:
<br />0 Not p egnantwakin past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant wants 42 days or death
<br />❑ Not pregnant, -but ptrgnait 42 days to 1 year before death
<br />❑Unknown If pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natwal 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide [3 Could not be *tumbled
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Q Other '(Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?:
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEi1TH?
<br />CI yes ❑No
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURYAT WORK?
<br />El YES ❑ NO
<br />.22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJUR:' STREET &NUMBER, APT.NO.
<br />CITY/TOWN .
<br />ZIP Carta
<br />0
<br />O
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 5, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 7.2019
<br />23c. TIME OF DEATH
<br />10:47 AM
<br />3d. 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 />Chad Vieth, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES &J NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGN
<br />(Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />240. On the basis of examination and/or investigation, M my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not ApF:Icable If 28a is NO 0 YES 0 NO
<br />28b.. ATE FILED BY REGISTRAR (Mc., Day, Yr.)
<br />January 10, 2019
<br />
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