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<br />WHEN THIS r 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 ,e,,
<br />A
<br />DATE OFISSUANCE
<br />9/13/2019 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT GP REALM
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTHHiCATe OP DEATH'
<br />201906623
<br />RUSSELL HALER
<br />LINCOLN, NEBRASKA
<br />1. DECEDEN'F$.NAME (First, Middle, Last, SLAV)
<br />Richard $toy Mlles
<br />4 C11'K AND STATE OR'rMRRI?ORY, OR FOREIGN COUNTRY 0f t3U2TH
<br />it
<br />«,9
<br />nMetres'
<br />3a, AGE « Las
<br />Birthday
<br />8b. LINO
<br />M
<br />1 YEAR
<br />DAY$
<br />2. SEX _
<br />Male
<br />60. UNDER
<br />HOURS
<br />1 DAY
<br />MINS.
<br />3. DATE OP DEATH (Me., Day, Yr.)
<br />piarrtber204
<br />8. DATE OF BIRTH (Mo. Day,
<br />J •10
<br />1'4
<br />T. SOCIAL SECURITY NUMBER
<br />5Q7..50+7584
<br />tib. FACiLITY•NAME fit not )rilititution, give ENVOI and t urnber)
<br />CHI Health St. Fr(>Incis
<br />Se. CITY OR TOWN OF DEATH (lneittde tip Cede)
<br />Grand island 613803
<br />aa. RE$IDENCE.BTATB - 8b, COUNTY
<br />Nebraska Hai
<br />3d. 8tM!T AND NUMBER
<br />103B.ffeloGas 3 •e
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Melrriad 0 Never Married
<br />❑ Mervied. bat separated 0 Widowed 0 Divorced 0 Unknown
<br />Oa. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® Bp/Ouoatient
<br />❑DelA
<br />OTHER Nuralirg HomNLTC
<br />[ DesedsreVa Hors
<br />0 Other ISP08ify)
<br />ed. QOUNTY or DEA
<br />Hall
<br />❑ Hospice Facility
<br />Co, CITY OR TQWN
<br />re land
<br />8e. APT. N.
<br />10b, NAME OF SPOUSE (First, Middle. Last,
<br />Nola Nola n
<br />tit. YIP. CGDE 8g. INSIDE CITY LIMITS
<br />6003 RI YES Q NO
<br />8ufflit) if wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Roy Miles
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Veda Mae Standley
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. M('THOD Of DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Otber(Specify)
<br />14a, INFORMANT -NAME
<br />Nola Mijs
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />f18b. LICENSE NO.
<br />14b, RELATIONSHIP TO DECEDENT
<br />18c. DATE (MO., Pay, Vr )
<br />September 10, 2019
<br />STATE
<br />Nebraska
<br />1Tb. A(p Coda
<br />68862
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY i TOWN
<br />Gibbon
<br />17a. FUNERAL NOME NAME AND MAILING ADDRESS (Street, City or Town, Stall)
<br />Ord Memorlel Chanel. Inc.. 005 North 28th Street. PO Box 230. Ord, Nebraska
<br />)
<br />a. PART L fintgr tho;hejn of ao fts•,dloeases, injuries, or complicatlons4hgt directly caused tis death, 00 NOT anter terminal Wept) such as cardiac angst
<br />tpyahatVy soon, Of Minp?C.tdor fibrillation without Showing iM stiology. 00 NOT ASSR1VI ATI. Inter only one dd>lte Mt a lin},. Add additional Tine p neaaaeary•
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CADE! Whorl a) Unknown Natural Causes
<br />diaeaea er senditien raauit)na
<br />In deathf
<br />•segaplfaliytwat sdndhlens, n
<br />anyr,t0. gding 1a Ike Cauaa Iltddk:
<br />on line O.
<br />APPROXIMATE INTIERVAI.
<br />Onset to deeth
<br />1 Hour
<br />DUE TO, OR A4 A CONSEQUENCE OF:
<br />b)Cardiac Arrest Secondary To Eleotrerneohanica) Dissociation
<br />onset
<br />DU 70, OR A8 A CON$EOUENCE OF:
<br />Smooths UND!NLYING cAu88 a)
<br />(dislike 6r Sleevelet Wooed:
<br />u"""" $w"1" 4e"p1) DUE TO, OR ASA CONSEQUENCE OF:
<br />L $T'. ..
<br />d)
<br />onset to death
<br />oneat to death
<br />1E. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not re0uiting in the underlying cause gluon In PART 1.
<br />Chronic 0bletrttctive Pu(monaly Disease, Systemic Lupus, Erythemetosu8, Diabetes Mellitus Type 2, Hyperlipidemia, Chronic
<br />Kidney Disease Stage 2',>
<br />18, WAS MEDICAL EXAMINER
<br />OR CORONA;$ CONTACTED?
<br />❑ YES )bp NQ
<br />0. IF FEMALE',
<br />0 Not pressen* Within PAM Mr
<br />❑
<br />Pregnant at ams of death
<br />tfet **Pulm. put ereanant within at days oI death
<br />0 1101 "gni*, WA eISIIII ret 41 day, to 1 veer baton death
<br />0 Unknown If preenso within the past year
<br />21a. MANNER OF DEATH
<br />El Nature, ❑ Homicide
<br />0 Accident 0 Pending lnvestigltion
<br />0 amide 0 Gould not be determined
<br />210. IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?:
<br />0 Driverl0parator
<br />0 Passenger
<br />0 YES al NO
<br />Podasirlon 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />Q WISP (Specify) TO COMPLETE CAUSEDP 01EATI4?
<br />❑YES 0 N
<br />22e. PLACE OF INJURY -At home, farm, street, factory. office buliding, construction site, oto. (Specify)
<br />22a. DATE 01' INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />D YEs ONO
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />223. LOCATION OF INJURY • STREET 4 NUMBER, APT.NO. CITYiTOWN
<br />23a. DATE d#' DEATH (Mo., Day, Yr,)
<br />23b. DATE SKIM (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />1d. To the bort of my knowledpe, death occurred at the time. date and place
<br />and dila to the cause(*) stated. (Signature and Title)
<br />STATE ZiP CODR
<br />44it. DAle SIGNED (Mo., Day, Yr.)
<br />September 9, 2019
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.
<br />September 9. 2019
<br />24b. TIME OF DEATH
<br />02:30 AM
<br />24d, TIME PRONOUNCED DEAD:::
<br />02:3tLAM
<br />pee. On the bathe of esaminaeon antler Investigation, In my 'Millen deatk eecurred at
<br />the time, date and plods and duo to the cauea(a) stated. (61gmture and Taie)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />S. DID TOGA "• USE,. ,4NTRIBUTE TO THE DEATH?
<br />EYES 0 NO PROBABLY ® UNKNOWN
<br />21. NAME TITLE AND AD RLS$ OF CERTIFIER (Typo or Print
<br />Sarah Hinrichs, Mai) Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 88801
<br />285. REGISTRAR'S SIGNATURE
<br />21a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YEs 2]NO
<br />21b. WAS CONSENT 0 • NTE
<br />Not Applicable if 28a Is NO 0 YE8 ❑ NO
<br />128b. DATE FILED BY REGISTRAR (Mo.a Day, Yr.)
<br />September 10, 2019
<br />
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