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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 />3/30/2020
<br />LINCOLN, NEBRASKA
<br />202002391
<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 />CE � ry t i;ft 14(ittlStS9,0
<br />20 03790
<br />E
<br />eg
<br />e23
<br />t
<br />g 10a. MARITAL STATUE
<br />1. DECEDENTS -NAME (PUN, Middle, Last, Suffix)
<br />Shelly Lynfl Rapp
<br />4. CITY, AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Holdrege, Nebraska
<br />L SOCIAL SECUR(TY NUMBER
<br />507-96.8775
<br />5a. AGE Last Birthday
<br />(Yrs )
<br />58
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />Sc. CITY OR TOWNOF DEATH (Include Zip Code)
<br />Grand Island 68803`
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />513. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MO, Day, Yr.);:,
<br />March 16, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />September 7, 1961
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />❑.HospIce FacUity
<br />9d. STREET AND NUMBER
<br />4171 Iowa Avenue
<br />9e. APT. NO.
<br />19f. ZIF CODE
<br />1 68803
<br />99. U'SIDE CITY UNITS
<br />ipi YES 0 NO
<br />0
<br />u
<br />Lit
<br />81
<br />ar
<br />AT TIME Lb. DEA rHmamma IJ1,1eV9:Ma.rind. .rs.;iJra.._OFui.w-A'I:a„
<br />9) 0 Married, but separated
<br />❑Widowed 0 Divorced 0 Unknown
<br />Brian Keith Rapp
<br />11, FATHER'S -NAME (First,: Middle, Last, Suffix)
<br />Glenn Franklin Mcil.nturf
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />12. MOTHER'S -NAME (First, Middle, Ma den Sumame)
<br />ll1 r .
<br />14a. INFORMANT -NAME
<br />Brian Keith Rapp•
<br />Joy Ann Viles
<br />14b. RELATIONSIBPTO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />Il Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER! LOCATION: CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH {See instructions and examples)
<br />18. PART 1. Enter the chain of events- -diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respintory 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 CALK* (Final
<br />disease or condition reselling
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Squamous Cell Cancer Of Tongue
<br />in death} DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially net conditions, If b)
<br />any, leading;to the .gwsa;fisted
<br />,.
<br />on line a
<br />16c. DA"E (Mo., Day, Yr.)
<br />March 18.2020
<br />STATE
<br />Nebraska
<br />17b.Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />3 Month
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EnterttlaUNDERLYINO CAUSE c)
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onaet to death
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Psoriatic Arthritis, Cholecystitis
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />IE Not pregnant within past year
<br />0 Pregnant et eine of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />Nm orngnent, but 'regnant 43 efye to 1 year heron death
<br />❑ Unknown If pregnarttwithin the put year
<br />21a. MANNER OF DEATH.
<br />Natural ❑ HomiClda
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. W TRANSPORTATION INJUR
<br />0 DnWt/Operator
<br />0 Pauenger
<br />0 Pedestrian
<br />11 rxh+•'Specifyt
<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 />22a. DATE
<br />OF INJURY (Mo,, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify}
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />12
<br />130 I
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 16, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 17, 2020
<br />23c. TIME OF DEATH
<br />10:55 AM
<br />1311 -To the beet of my: knowledge, death occurred at the erne, date and place
<br />and due to the cause(s) stated. (Signature and TSN)
<br />Travis S. Hageman, MD
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death Wetted et
<br />the time, date and place and due to the cause(s) stated. (Signature 04 1104
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ®NO
<br />25. DIDTOBACQO USE CONTRIBUTE TO THE DEATH?
<br />❑:YES al NO 0 PROBABLY 0 UNKNOWN
<br />17. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 25, 2020
<br />
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