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t lj NAMPgamm ifltg109961 iEaec a ' STATE 0 E Sly 111S� atr tiYr�)l aaM,we ,446INITIYltfW ..... 140100ITi t li ))ad�r lotto :,. ,' *yt99trlkylfittAset ..,' NIIr6rPD.,rsc WHEN ! THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 7/21/2021 LINCOLN, NEBRASKA 202108091 )114. 41 41.44.fy SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 09226 1. DECEDENTS -NAME {First, Middle, Last, Suffix) Larry Eugene Shaw 2. SEX Male 3. DATE OF DEATH (Mixt Day, Yr.); July 13, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Oxford, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) 7. SOCIAL SECURITY NUMBER 506.46.5331 8h. FACILITY.NAME.1tf'not Institution, give street and number) Tiffany Square Care Center 8& PLACE OF DEATH HOSPITAL ❑Inpatient ❑ ER/Outpatient ❑ DOA November 21, 1939 OTHER ® Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) Hotipice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island led. COUNTY OF DEATH Hall 9d. STREET AND NUMBER 1041 South Pine Street 106. MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married 0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown 9e. APT. NO. 9f. ZIP CODE 68801 Sg. INSIDE CITY LIM)T$ YES D NO 10b. NAME OF SPOUSE (First, Middle, Laat, Suffix) If wife, give maiden name Susanne Clarine 11. FATHER'S -NAME (First, William Shaw Middle, Laat, Suffix) 13. EVER IN U.S. ARMED FORCES? (Yes, No, or Link.) No Give dates of service if Yes. 14a. INFORMANT -NAME Susanne Shaw 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jennie Andrews 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial ❑ Donation ( Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed led. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 16b. LICENSE NO. CITY / TOWN Gibbon 16c. DATE (Mo.. Day, Yr.) July 14,;2;021 STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral`, Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 14. PART 1. Enver the chain of events- diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. Add additional Tines N necessary. IMMEDIATE CAUSE: a) Hypoxic and hypercapnic Respiratory Failure IMMEDIATE CAUSE tPMal disease or condition resulting' in death)' Sequentially list conditions, If any. leading to the cause listed online a. DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Obstructive Pulmonary Disease 17b. Zip Code 68801:. APPROXIMATE INTERVAL onset to death Chronic DUE TO, OR AS A CONSEQUENCE OF: Enter eft UNDERLYING CAUSE c) (dlesese or injury that initiated musette death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 1$, PART Il. OTHER SIGNIFICANT CONDITIONS-Conditlons contributing to the death but not resulting In the underlying cause given in PART I. Atrial Flutter, Altered Mental Status, Aspiration 20. IF FEMALE: ❑Not pregnant within past year 0 Pregnant alma today* ❑.:nof pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown N pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO. 21a. MANNER OF DEATH Natural ❑ Homicide 0 Accident 0 Pending investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?` ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Eiti No 21d. WERE AUTOPSY; FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES Q NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sit4 etc, (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 221, LOCATION OF INJURY STREET & NUMBER APT.NO. a. 23a. DATE OF DEATH (Mo., Day, Yr.) July 13, 2021 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) July 14.2021 23c. TIME OF DEATH 12:25 AM 23d. To the hest of my knowledge, death occurred at the time, date and place and duato lea -causes) stated. (Signature and Title) Ryan D Crouch, DO STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination andlor Investigation, In my opinion death occurred at the time, date and place and due to the causes) stated. (Signature 00 lite) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? El YES 0 NO ❑ PROBABLY 0 UNKNOWN 27. NAME, TITLE AND ADD/011)F CERTIFIER (Type or Print Ryan D Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ®NO' 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO 0 YES 0NO' 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 19, 2021 1 w 0)