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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 />3/16/2020
<br />LINCOLN, NEBRASKA
<br />20210077
<br />a�'S k4.
<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 02704
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ralph Mead
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 24x 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7.,SOCIAL SECURITY NUMBER
<br />506-.2-6377
<br />8b. FAC!UTY-NAME (11 not Institution, give street and number)
<br />0
<br />IVA Medical Center -Grand Island
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />II Grand Island 68803
<br />2
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />90
<br />5b. UNDER 1 YEAR
<br />60, UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OFDEATH
<br />HOSPITAL LI MIDI:
<br />-e u,..^'r,nt
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, W.)
<br />July 4, 1929
<br />OTHER IX1 Nursing Home/LTC
<br />a'.1rte. u- 11,,,1
<br />❑ Other(Spacly)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />r i
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2222 N Wheeler Ave
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Mewled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (PIM, Middle, Last, Suffix)
<br />Frank Mead
<br />13. EVERIN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link.) Yes . 09/18/1946-08/24/1948
<br />15. METHOD OF DISPOSITION
<br />❑ Buttal Donation
<br />[ Cremation ❑ Entombment
<br />O Removal 0 Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9a. INSIDE CPPV LIMITS •
<br />® YES ©NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give madden nam`
<br />Gladys Lee
<br />14a. INFORMANT -NAME
<br />Gladys Mead
<br />16a. EMBALMER -SIGNATURE
<br />Benjamin Hall
<br />12, MOTHER'S -NAME (First,
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Anatomical Board
<br />Sylvia Saunders
<br />1Sb. LICENSE NO.
<br />1305
<br />Middle, Malden Surname)
<br />CITY I TOWN
<br />Omaha
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.),
<br />February 24, 2020
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Nebraska Anatomical Board, 986395 Nebraska Medical Center, Omaha, Nebraska
<br />17b. ZipCode
<br />68198.6395
<br />CAUSE OF DEATH (See Instructions and examples'
<br />18. PART I. Enter the chain of events- -diseases, Injuries, or complleatlon.Mat 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 One. Add additional lines If necessary.
<br />:,.
<br />; a6see111 at el:Mdaion rauk:n}
<br />- Irtmum,
<br />sr Sequentially list conditions, If
<br />any,_ Nading to Sts cause 9sted
<br />on qru 4.
<br />Ental the t5NOE1tLYING CAUSE
<br />(diteaor injury that MAW
<br />ss ed
<br />the events resuldng In death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />-' Acute- . whin+i: C'-gect;w.o I -•:.An cx!,
<br />$:cut�� „
<br />DUE TO, OR AS A CONSEQUENC. OF:
<br />b) Atherosclerotic Heart Disease
<br />APPROXIMATE1NTERVAL
<br />onset to death
<br />tit- ww -
<br />0,1110 tc
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to depth
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />16. PART 11. OTHER SIGNIFICANT CONDITIONS-Cpnd(Bons contributing to the death but not resulting in the underlying cause given In PART I.
<br />Diabetes Mellitus Type 2, COPD,Chronic Renal Failure
<br />20. IF FEMALE:
<br />❑ ;Nat pregnant within peat Year
<br />❑ Pregnant* time cif death
<br />s
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 13 days to 1 year before death
<br />❑ ;unknown If Proilnefit wdthln the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ HOMIOde
<br />❑ Accident ❑ Pending investkratton
<br />0 Suicide ❑ Could not be determined
<br />21b, IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />❑ Patentor
<br />Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?'
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSYFENDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />2244 DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At horn
<br />nit, street, factory, office building, construction she, de.($j
<br />22d. INJURY AT WORK?
<br />❑ YES ,❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />wi
<br />e 22f LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />0.
<br />STATE
<br />MP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 1240, DATE SIGNED (Mo., Day, Yr.)
<br />February ry 24 2020 !
<br />23b. DATE SIGNED Mo., Day,Yr.)23C. ,,,AEOF deATh 1 •4c. ,'RVhaiuNl;Er3 DERV
<br />g r c February 2,o. 2020 03:10 FM ~pass
<br />. To the bat of my kiwrMedge, death occurred el the time, date and place " i 24s. on **bed. of axamine ron andter Investigation, In my opinion atrth OCiunOd et
<br />E and duetattle caused') stated. (Signature and Title)
<br />tat One, date and place and due to the cause(,) stated. (Siprture ant Tate)
<br />>; Shawn S. Lawrence, MD
<br />24b. TIME OF DEATH
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES IJ NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES' EI NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26. is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />4../1e�-
<br />CrN
<br />f""3
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 4, 2020 CO
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