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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 />4/17/2020
<br />LINCOLN, NEBRASKA
<br />51
<br />d
<br />202007960
<br />)0.44...11 8#0.6L1414tit
<br />SARAH BOHNENKAMP f
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Michael Lyman O'Brien
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Salt Lake City, Utah
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />513. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />20 04706
<br />3. DATE OF DEATH(Mo., Day, Yr.)
<br />April 8, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 12, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />525-96-3281
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />Ed. STREET AND NUMBER
<br />4144 Vermont Avenue
<br />He. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />8y. INSIDE CITY LIMITS
<br />® YES ; 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donna Cain
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Russell Cleaborne O'Brien Alberta Lyman
<br />Middle, Malden Surname)
<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 />Donna O'Brien
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />E Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day, Yr.)
<br />April 13, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfsl Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. 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 showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE (final
<br />disease or condition resulting:
<br />IMMEDIATE CAUSE:
<br />a)Acute On Chronic Respiratory Failure
<br />In death) - DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Pneumonia
<br />any, leading to the cause listed
<br />on lino*
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EntertheUNDERLYING CAUSE c)Chronic Respiratory Failure With Hypoxia And Hypercapnia
<br />(disease or injury that initiated
<br />170. ZIp Code
<br />68801 •
<br />APPROXIMATE INTERVAL
<br />onset to. death
<br />Days
<br />onset to death
<br />Days
<br />onset to death
<br />Years
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)Chronic Obstructive Pulmonary Disease
<br />onset to death
<br />Years,
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Alport Disease
<br />20. IF FEMALE:
<br />❑ Not pregnant within pest year
<br />❑ PngnaM at theaof death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22f. LOCATION Of INJURY
<br />21e. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 DriveriOperator
<br />❑ Paesenosr
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />EYES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ..
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />iTREET 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 8, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />April 8 2020
<br />23c. TIME OF DEATH
<br />05:25 AM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due tattle cause(s) stated. (signature and Title)
<br />Zachary W. Meyer, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E No © PROBABLY 0 UNKNOWN
<br />g
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />245. On the basis of examination and/or investlga ion, in my opinion death occurred at
<br />the time,date and place and due to the causes) stated. (Signature and Tice)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO Q YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />G�z4% Bs>n,m-
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />April 14, 2020
<br />
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