|
iekkeiWA
<br />(4h''?da"3t
<br />79tAflAWNatt3lii
<br />rlyrNia4'"f�"',.
<br />tiyotifiTas,i�iD; uuu/Rabi,10p iiTraawALdtlu,,,,,,rtiIlilby,,,,,, ,uu.440/14imait 411
<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 />+xRttWiWN\ �rQ96ft/)t'Ilfft0111 ,t 9ItiEWi4MQ@\T 75Yy�tIAt'i;�flA�td\%' IRrrryir\\Fras
<br />DATE OF ISSUANCE
<br />11/30/2018
<br />LINCOLN NEBRASKA
<br />202004286
<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 />I1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Richard H Sullivan
<br />2. SEX
<br />Male
<br />RGy��h'�Plllatrtl w�9t
<br />ra33��, �rfi
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 7, 2018
<br />.L CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />f�0
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-40-1565
<br />AGE - Last Birthday
<br />(Vfs.)
<br />80
<br />8b. FACIUTf-NAME (If oot:institution, give street and number)
<br />618 W. 9th
<br />t 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />'i7
<br />F.
<br />ro
<br />3
<br />d
<br />E
<br />0
<br />3
<br />0
<br />m
<br />9e. RESIDENCE,;
<br />Nebraska .:
<br />9d. STREET AND NUMBER
<br />618 W. 9th
<br />9b. COUNTY
<br />Hall
<br />10a. mAKITAL STATUS AT T ME OF DEATH 0 Married E Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Joseph L Sullivan
<br />18.
<br />EVERIN U,S :ARMED:FORCES? Give dates of service if Yes.
<br />(Yes No or Unk.) No
<br />15. METHOD OFDISPOSITION
<br />® Burial °Q Donation
<br />❑ Cremation 0 Entombment
<br />[];Removal :'Q OthoiSpecify)
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island. Nebraska
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL. 0 Inpatient
<br />Q ER/Outpatlent
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE C1TY LIMITS"
<br />® YES 0 NO
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Gloria Reichmann
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ruth W Hastings
<br />14b. RELATIONSHIP TO DECEDENT:<:
<br />Sister
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Ma, Day, Yr)
<br />November 14, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island
<br />Grand Island City Cemetery
<br />STATE
<br />Nebraska
<br />17b. 2{p Cods
<br />68801
<br />CAUSE OF DEATH {See instructions and examples)
<br />ts. PART I. Enter iiia; Shaky Cr events --diseases, injuries,or complications -that directly caused the death. DO NOT enter terminat events such as cardiac arrest,
<br />respiratory arrest, or ventYcutat fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (final a) Undetermined Natural Causes
<br />disease or condition resulting
<br />nbatbj
<br />Sequamia)ly li$ S'4ndthons If
<br />any, teeding eco thecause Iteted-
<br />on line a.
<br />Enter the (JNDERLYINO CAUSE
<br />(dieeenudrinjurythat tmtlated.,
<br />the eVents reeuit rain
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />APPROXIMATE INTERIM.
<br />onset to death
<br />onset. ta deMti:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />LAST DUE. TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset to death
<br />18. PART I I. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in
<br />20. IF FEMALE
<br />0 Not pregnant- within past year
<br />❑ Pregnant at time of death
<br />Q Not Pregnant: bid Ping/tent within 42' days of death
<br />Blot preSnatd,but pragnarh 43 days to 1 year before death
<br />u. flnirrroen it p1-egnent Walton die past year
<br />,2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />ea
<br />22c418,1JURY AT WORK .?
<br />YES Q NO
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide © Could not be determined
<br />22b. TIME OF INJURY
<br />PART 1,
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF:DEATH?
<br />O YnS r`1 Nr3
<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 />re
<br />c:
<br />H
<br />8
<br />rere
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. PATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN STATE
<br />23c. TIME OF DEATH
<br />3d. To the lest of my knowledge, deathoccurred at the time, date and place
<br />and due to thecause(s) stated. (Signature and Title)
<br />25. pip. TOBACCO USB CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />- j27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />it Dave Medlin, Half: Deputy County Attorney, 231 S. Locust, Grand
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />November 21, 2018
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 7, 2018
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />10:30 AM
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s)stated. (Signature and Title)
<br />Dave Medlin, Hall Deputy County Attorney
<br />TISSUE DONATION BEEN CONSIDERED?
<br />ENO
<br />Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES Q NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day Yr)
<br />November 27, 2018
<br />
|