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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 />8/9/2021
<br />LINCOLN, NEBRASKA
<br />202108090
<br />r
<br />kr:il I ret_
<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 />21 09772
<br />0
<br />m
<br />E
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Michael S Williams
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (100,128Y, Yr.)
<br />July 24, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Unknown, Texas
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />72
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (Mo. DaY, Yr.)
<br />November 1, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />506-02-5557
<br />8b.''FACILITY-NAME (N' not institution, give street and number)
<br />2920 Bock Ave
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2920 SotkAYE/
<br />9b. COUNTY
<br />Hall
<br />105." MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Unknown Williams
<br />13. EVER IN U,S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />0 Burial ❑ Donation
<br />[ Cremation ❑ Entombment
<br />❑ Removal ' Pother (Specify)
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />I Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑ Hospice FaCSity
<br />99. INStDE CITY LIMITS
<br />MITS
<br />YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sandy
<br />Unknown 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />14a. INFORMANT -NAME
<br />Sandy Williams
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />July 27 ;2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<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 />CAUSE OF DEATH (See instructions and examples)
<br />111. PART I. Enter the chaln 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 />in (eath)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease or injurythat initiated
<br />the events resulting in death)
<br />LAST
<br />18. PART I1. OTHER SIG
<br />IMMEDIATE CAUSE:
<br />a)Lung Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Months
<br />onset to death
<br />one
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />IFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant within peat year
<br />0 Pregnant at time of deathfl-
<br />❑.:Not pregnant, butpregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown B. pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 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 0 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc,1Specffy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATIONgOF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 24, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Juiv 27, 2021
<br />23c. TIME OF DEATH
<br />09:48 PM
<br />23d. Tothe beet dray knowledge, death occurred at the time, date and place
<br />am due to ttte'cause(s) stated. (Signature and Title)
<br />Zachary W. Meyer, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIPCODE
<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, date and place and due to the cause(a) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YESi
<br />DNo:
<br />27. NAME, TiTkE 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 />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 2, 2021
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