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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 OF ISSUANCE
<br />3/24/2020
<br />LINCOLN, NEBRASKA
<br />202002000;
<br />j 'tr'i%.i) l���%iJtaf.f
<br />SARAH BOHNENKAMP
<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 />19 08907
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Cynthia Ann Ryan
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day; Yr.)
<br />July 11,2019
<br />4. CITY AND STATE OR. TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Denver, Colorado
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />5b, UNDER 1 YEAR
<br />5e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,Yr.)
<br />February 1, 1949
<br />0 Hospice Facility
<br />7. %CUM. SECURITY NUMBER
<br />522.68-3894
<br />8b.'FACiUTY-NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN QF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8e. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />....]
<br />O ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />912 S. Gteenwhich St.
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITYLJMITS
<br />@ YES ❑ NO
<br />10a.' MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First,' Middle, Last, Suffix) If wife, give maiden name
<br />Timothy P Ryan
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12 MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Geraldine Moore
<br />Charles T Potter
<br />13.,EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Heather Goering
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Budel ;' ❑ Donation
<br />Cremation ❑ Entombment
<br />Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />July 12, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services Gibbon
<br />CITY /TOWN
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St., Grand Island, Nebraska
<br />17b. Zip Code-
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />5 10. PART!. 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 showino the 'holopv. DO NOT ABBREVIATE. Enter nnly one cause nn a Tins. Add eddlinnal. lines N nesew!ry.
<br />E IMMEDIATE CAUSE (Final
<br />a ai* ase or condition resulting
<br />0I
<br />re
<br />d
<br />0
<br />a
<br />ection 30-2413, dcamands
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />online a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) Ruptured Abdominal Aortic Aneurysm!
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onse
<br />to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART tl. 0
<br />ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. was MEDICAL: EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:
<br />Not pregnant within 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 />❑ Unknown if Pregnant within the put year
<br />22a, DATE OFINJURY (Mo, Day, Yr.)
<br />22d. INJURY AT WO lit?
<br />❑Yes NO
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident ❑ Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />© Pedestrian
<br />0 Other(Specify)
<br />22c. PLACE OF INJURY -At home,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22 , LOCATION! OF INJURY; STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />Sit
<br />J 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />123d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due -tette: caueala) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
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<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />rm, street, factory, office building, construction site, etc. (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />July 12, 2019
<br />24b. TIME OF DEATH
<br />10:06 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />July 11, 2019
<br />24d. TIME PRONOUNCED DEAD
<br />10:06 AM .
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the lime, date and place and due to the causes) stated. (Signature and TSN)
<br />Martin Klein, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION.. BEEN CONSIDERED?
<br />❑ YES ENO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />...z /CHOW
<br />-------
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 YES
<br />❑ N4
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 16, 2019
<br />
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