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<br />STATE OF NEBRASKA �,iy,,
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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 Dh9O6373
<br />SITORY OR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/21/2018
<br />UNCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />INTERIM 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. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Edward Michael Ryan
<br />2. SEX
<br />Male
<br />t
<br />Oligta 100104*,
<br />IlKt4&hyPsieh
<br />4�Ed�;AIDiO� I/!�
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10, 2018
<br />4, CITY; AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-44-6721
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />81,. FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />77
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,Yr4
<br />November 25, t
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />940
<br />0 Hospice Facility
<br />.t. �8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island ;8503
<br />io
<br />pit RESIOgh,r`c-nTp T'= 7 IOh. COUNTY
<br />tb
<br />.O2
<br />to
<br />i
<br />Nebraska Hall
<br />8d. STREET AND NUMBER
<br />3236 Westside •
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c: CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY' LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ® Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Midrie, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Gerald M Ryan
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bernice Dolan
<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 />Tom Ryan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Brother
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑;Removal ;❑ Other4SpecIfy)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />September 11 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate)
<br />Curran Funeral Chapel. 3005 S. Locust St., Grand Island. Nebraska
<br />CITY /TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b, Zip code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18 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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause: on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Sudden Cardiac Death Due To Acute MI
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Arteriosclerotic Cardiovascular Disease
<br />DUE TO. OR AS A CONSEOUENCE OF:
<br />c) Longstanding Type Two Diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />onset to death
<br />1 Year
<br />onset to death
<br />10 Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />CA Of Colon, Hypertension, Chronic Kidney Disease Stage 4, Anemia
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 42 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />pedestrian
<br />o Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED7:.
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH/
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />d. INJURY AT WORK?
<br />AYES 0 N
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8, NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />z
<br />September 10, 2018 p g Z
<br />23c. TIME OF DEATH I y
<br />23b. DATE SIGNED (Mo., Day, Yr.)Mema
<br />Se
<br />ber 10, 2018 03:02 AM . €
<br />3d. To the best of my knowledge, death occurred at the time, date and piece z
<br />and due to the cause(s) stated. (Signature and Title) g 0 p
<br />Steven Huselt, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the bass of esaminadon and/or Investiga on, 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 USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? I'
<br />❑ YES II NO 0 PROBABLY 0 UNKNOWN ❑ YES �► NO I Not Aoolicahle if 26a Ie Nil n vice
<br />127. ".i ,LT nivt sawtica8 OF CtR I IF1ER [type or Print)
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a :REGISTRAR'S SIGNATURE
<br />"
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />September 14, 2018
<br />
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