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<br />�� STATE OF NEBRASKA
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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 />4/21/2020
<br />LINCOLN, NEBRASKA
<br />202009141
<br />611,41..47,6
<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 />20 04753
<br />1. DECEDENTS -NAM (First, Middle, Last, Suffix)
<br />Wayne E Grachek Sr
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo„ Day, Yr.)
<br />April 11, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Peoria, Illinois
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH(Mo., Day, Yr,)
<br />February 9, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />354-2&-'i 166
<br />• 8b. FACILITY -NAME (If not Institution, give street and number)
<br />a • 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 />18a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />ta.Rospice Facility`
<br />9d. STREET AND NUMBER.
<br />1615 S. Blaine Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g, INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />v
<br />• 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Carolyn L Todd
<br />E 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />• Joseph E Grachek Sr
<br />13. EVER IN U.S. ARMED'FORCES? Give dates of service if Yes.
<br />c (Yes, No, or Unk.) NO
<br />0
<br />O 15. METHOD OF DISPOSITION
<br />❑;Burial ❑Donation
<br />El Cremation?0Entombment
<br />c❑ Removal "❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Carolyn L Grachek
<br />Mary H Patton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 14, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />c 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />8 Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />to
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />€ I18. PART I. Enter tea chain of events- -diseases, Injuries, or complicationsthat directly caused the death. DO NOT enterterminal 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:
<br />a IMMEDIATE CAUSE (Final a) Cardiac Arrest
<br />E disease or condition resulting
<br />in death)>
<br />fit Sequentially Ilst conditions, If
<br />any, leading to the cause listed
<br />::... on OM 6._.. _._..
<br />2
<br />0
<br />O
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />- I
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Chronic Systolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Coronary Artery Disease
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />onset to death
<br />2 Years
<br />onset to death
<br />Chronic
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />« 18, PART g. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Atrial Fibrillation ,chronic Kidney Disease, Hypertension , Obesity
<br />co
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />ie 0. IF FEMALE:
<br />0 Not pregnant within pant year
<br />a 0 Pregrwtd at tltae et 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 put year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<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 OF INJURY(Mo.i Day, Yr.)
<br />N
<br />�
<br />E 22d. INJURY AT WORK?
<br />• ❑YES 0 N
<br />22b. TIME OF INJURY
<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 />No
<br />M
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 11, 2020
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 14, 2020 05:00 PM
<br />3d. To the beat of my: knowledge, death occurred at the time, date and place
<br />and due OD the tiause(s) stated. (Signature and Tale)
<br />Ryan D. Crouch, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
<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 occurred at
<br />the time, data and place and due to tea Cause(s) stated. (Signature and VW)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO J YES
<br />0 N
<br />127. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 7 pp
<br />Gt/Z4� Ods01---2ei?,!'.a,rkL
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 15, 2020
<br />1
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