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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 />7/14/2021
<br />LINCOLN, NEBRASKA
<br />20210798,
<br />-•'://7}70564.4414401
<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 />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased ate filed with the county court to the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald Patrick Whelan
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo„ Day, Yr.),
<br />July 5, 2021
<br />4, C(TY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Lae '<Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />79
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 28, 1942.
<br />7. SOCIAL SECURITY NUMBER
<br />508-48-2091
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®'Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />❑'ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2519 Park Drive
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. tNSIDE CITY wars
<br />1 vas ❑ NO
<br />led, MARITAL. STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden naive
<br />Patricia Diane Dills
<br />11. FATHER'S.NAM£ (First, Middle, Last, Suffix) ( 12. MOTHER'S -NAME (First, Middle, Maiden Surname);
<br />Michael Whelan Bedonna " Mitchell
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yea.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Patricia Diane Whelan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />]
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />July 8, 2021
<br />Cremation 0 Entombment
<br />[ ] Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Cods
<br />68801
<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 />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc.lAdd additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE tpntal : a)Sepsis Syndrome
<br />disease or condition resulting
<br />onset to death
<br />48 Hours
<br />indel"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />aequentialy list conditions, if b)Cellulitis/abscess
<br />any, leading to the cause listed
<br />on fine it
<br />onset to death
<br />72 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYINt; CAUSE c) Immune Compromise
<br />(disuse or injury: that itutiated
<br />onsetto death
<br />6 Months '.
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)METASTATIC ADENOCARCINOMA LUNG
<br />onset to death
<br />1 YEAR,
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />HYPERTENSION
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF
<br />©..:Not
<br />0
<br />FEMALE:
<br />pregnant within past year
<br />Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />:❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />ElNot pregnant, but pregnant 43 days to 1 year before death
<br />OUnknown H. pregnant within the past year
<br />❑ Suicide ❑Could not be determined
<br />❑'Pedestrian
<br />ElOther (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site. etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF UJJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL. CERTFER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Julv 5, 2021
<br />�sz
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 8,2021
<br />23c. TIME OF DEATH
<br />01:00 PM
<br />x V
<br />1a.`8
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. TO the beat of my knowledge, death occurred at the time, date and place
<br />Mal due to die cause(s) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />Mx :74
<br />a i7 O
<br />1.-§
<br />24e, On the basis of examination and/or Investigation, in my opinion death matured at
<br />s) stated. (Signature and T
<br />the time, date and place and due to the causeTRIO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 YES 0 NO
<br />27. NAME, TIRE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Grouch, DO, 800 N Alpha St, Grand Island,
<br />Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATUREa�� �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 12, 2021
<br />
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