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6.42 RpOp a a:K't�'9etttltJDtD%. a . rsRt6fypj);(I;fN6tR-t, e -x.eia 6rAruntVDDS ra t�Attt�t'A@1... ��„aiee�a3I1)d Ir1{)a�A fr,rd�iS.'1h..lErc9ks�$d}�U{ttt,9tiy'�reii�r14tt$Z�Ai�, ' �3��a' (;it((!'(.lQt >�Mr4�`DImRai�i. i�E)0,1,4/3%� ti�tiY8 6 p19 i�5' s1 Fti1ic jrb�"4llM1f 5GaDD.z 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 OFISSUANCE 9/15/2021 LINCOLN, NEBRASKA Z. w « Cg u 202109171 t •1241/ SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Michael Anthony Enyeart 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 63 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 21 12068 3. DATE OF DEATH (Mo., Day, Yr.) September 3, 2021 6. DATE OF BIRTH No., Day, Yr.) January 31„ 1958 7. SOCIAL SECURITY NUMBER 505-80-1848 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Gland Island 68803 9a. RESIDENCE -STATE Nebraska Sb. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER 0 Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall © Hospice Facility 9d. STREET AND NUMBER 73 Koester Lake Be. APT. NO. 9f. ZIP CODE 68801 94. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name La Donna Moritz 11. FATHER'S -NAME. (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) • Burt Enveart Gloria Satterly 13. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 14a. INFORMANT -NAME La Donna Enveart 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑;Burial ❑ Donation Cremation ❑ Entombment ❑'Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 5, 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Jacobsen-Greenwav-Dietz Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, Injuries, or complications- hat 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 line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Adult failure to thrive IMMEDIATE CAUSE (Final disease or Condition resulting':, in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) anorexia arty, leading to the causelisted on line a. STATE Nebraska 1Tb. Zip, Code., 68873 APPROXIMATE INTERVAL onset to death. Weeks onset to death Weeks DUE TO, OR AS A CONSEQUENCE OF: Eater the UNDERLYINGCAUSEc) Metastatic Adenocarcinoma with unknown primary (dinettes or Injury that initiated the events resulting in death) LAST onset. .death DUE TO, OR AS A CONSEQUENCE OF: d) 18; PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I. adrenal insufficiency 20.1F FEMALE: 0 Not pregnant wimut peat year ❑ Pregnant at time of death ❑ Not pregnant, but (stagnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑YES 0 N 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger DPedestrian 0 Other (Specify) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®! NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑NO _. 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 2r. LOCATION OF INJURY;, STREET & NUMBER, APT.NO. 0 23a. DATE OF DEATH (Mo., Day, Yr.) September 3, 2021 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) September 5. 2021 23c. TIME OF DEATH 02:20 AM 23d. To the best of my knowledge, death occurred at the the, date and place and due to he cause(s) stated. (Signature and Thi) Vinay K. Singh, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO Q PROBABLY D UNKNOWN STATE 24e. 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 and/or Investigation, In my opinion detdh osdurred:et the time, date and place and due to the camels) stated. (Signature and Tele) 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO < ❑ YES ONO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Vinay K. Singh, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE lstil %�o�ize�lrz� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 15, 2021 i