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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 />10/31
<br />�
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />20190726
<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 />0
<br />•
<br />1. DECEDENTS•NAME"(First, Middle, Last, Suffix)
<br />Steven Robert Todd
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 20, 2019
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Valentine, Nebraska
<br />Se, AGE- Last Birthday
<br />(Yrs.)
<br />71
<br />db. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,.:
<br />February 14, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />505-56-4087
<br />. FACILITY -NAME Of notInstitution, give street and number)
<br />3335 13th St., Rvutn t739
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpadent
<br />0 DCA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />Other (spec iy)Cotn 1us•:er, lotel
<br />❑ Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68508
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska Hall
<br />9d. STREET AND NUMBER
<br />3012 Colonial Ln.
<br />8c. CITY OR TOWN
<br />Grand Island
<br />90. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g'INSIDE Crt LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />❑;Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE twat,
<br />Mary Colleen Mulliga
<br />n
<br />Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME {first, Middle, Last, Suffix)
<br />Robert Todd
<br />1 12. MOTHER'S -NAME (First, Middle,
<br />Erma Monroe
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OP DISPOSITION
<br />El Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal 0 Other(Specify)
<br />14a. INFORMANT -NAME.
<br />Mary Colleen Todd
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />October 23, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. F,1JNERALH(~1ME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Z/p Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART I. Enter The chain of events- -diseases, injuries, or compllcatlons.hat directly unread the deatlt. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without stowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add add0ional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Undetermined
<br />disease or condition resulting
<br />In death) :;..
<br />DUE TC, OR AS t CONSEQUENCZ )F:
<br />se,arentiaay list condhMns, I b) Probable Heart Attack
<br />any, teadino to the cause listed
<br />on lino a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Heartburn Type. Pain In Chest
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d) High Blood Pressure
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />High Cholesterol
<br />20. )FFEMALE:
<br />0 Not pregnant withitt past year
<br />0 Pregnant at time of death
<br />❑ ,Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑
<br />Unknown I pregnant withinthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />E] YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other(Speclty)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset
<br />onset to death
<br />Days
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?.
<br />❑YES 0 N
<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 & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />o
<br />gl
<br />w
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />3d. To the best of my knowledge, death occurred at ten time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />October 28, 2019
<br />24c. FTONCU'I�Er? DEAD (!4o., Day, Yr.
<br />October 20, 2019
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Unknown
<br />2' . T.M. PRr)NC. IIICED DEAN
<br />05:1 1 AM
<br />24e. On the basis of examination and/or Investlgetion, in my opinion death occurred at
<br />the drew, date and place and due to the cause(s) stated. (Signature and TIM)
<br />Bruce J. Prenda, Chief Deputy Lancaster County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? . 26b. WAS CONSENT GRANTED?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN ® YES 0 NO Not Applicable if 26a is NO Et YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Bruce J. Prenda, Chief Deputy Lancaster County Attorney, 575 South 10th St, 4th Floor, Lincoln, Nebraska, 68508
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Ma,; Day, Yr.)
<br />October 29, 2019
<br />
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