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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 />3/30/2018
<br />LINCOLN, NEBRASKA
<br />202107724
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<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />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 Perry Shriner
<br />. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-2854
<br />5e. AGE • Last Birthday
<br />(Yrs.)
<br />75
<br />8b. FACILITY -NAME (tf not Institution, give street and number)
<br />Nebraska Medicine
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 15, 2018
<br />6. DATE OF BIRTH (Mo Day,;
<br />January 11, 1.943
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />0 Hospice Facility
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1810 Ada St
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITYLIMITS
<br />® YES ❑ NO
<br />tea. MARITAL STATUS AT TIME OF DEATH I Married 0
<br />0 Married, but separated 0 Widowed 0 Divorced
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Oliver Perry Shriner
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service if
<br />(Yes, No, or Unit.) Yes : 03/11/1964-03/10/1966
<br />Never Married
<br />❑ Unknown
<br />Yes.
<br />leb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sheryl Yleen Ahlers
<br />12. MOTHER'S.NAME (First, Middle, Maiden Surname)
<br />Leona Curry
<br />14a. INFORMANT -NAME
<br />Sheryl Yleen Shriner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />0 Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 18, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<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 />1?b. Zip Cods
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />S. PART I. Etter the Chain Olin/tints- -diseases, injuries, or complications4hat 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:
<br />IMMEDIATE CAUSE (Final a) Multisystem Organ Failure
<br />distase or condition resulting
<br />in death)
<br />Sequentially list conditions, If
<br />any, leading fo Manaus. listed
<br />on line
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury: that irdtiat id.
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Fa ll
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to deatl7:'::
<br />11 Days
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset tadeath
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />History of Cerebral Vascular Accident With Residual Right Eye Blindness, Seizure Disorder, Hyperlipidemia, Hypertension
<br />20. If FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Nbt pregnerit, tical p1M.gn41d 43 days tot year before death
<br />❑ Unknown it pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />® Accident 0 Pending investigation
<br />❑ Suicide 0 Could riot be determined
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />a Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES 0 NO
<br />21e. WAS AN AUTOPSY: PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY:FINO(Nf3S AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />March 4, 2018
<br />22d. INJURY AT WORK?
<br />❑ YES 3 NO
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Mechanical fall down 13 stairs.
<br />22f. LOCATION OF INJURY - STREET i NUMBER, APT.NO.
<br />Unknown, Unknown
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Marco 15, 2018
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 16, 2018 10:07 AM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Lisa Lynn Schlitzkus, MD
<br />25. DID TOBAGO° USE CONTRIBUTE TO THE DEATH?
<br />0 YES Il NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Lisa Lynn Schlitzkus, MD, 983280 Nebraska Medical Center, Omaha, Nebraska;; 68198
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR ISSUE . • ATION BEEN CONSIDERED?
<br />YES ■ •
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑'YES E} NO
<br />28a REGISTRARS SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Ma., bay, Yr.) 1
<br />March 27, 2018
<br />
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