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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 />4/20/2021
<br />LINCOLN, NEBRASKA
<br />202112110 8 ,x, o,
<br />0832. 2. 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 02923
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Brett Aaron Shields
<br />2. SEX
<br />Male
<br />4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nebraska
<br />7, $OCTAL SECURITY NUMBER
<br />507.06-3882
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b'FACILITYNAMEOnot Institution, give street and number)
<br />2039 OSt., Apt. 103a
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68503
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Lancaster
<br />50
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Lincoln
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH'(Mo., Day, Yr.)
<br />February21, 2021
<br />6. DATE OF BIRTH (Mo.Day, Yr.)
<br />February 15, 1971
<br />OTHER 0 Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />0 Hospice Facility
<br />9d, STREET AND NUMBER
<br />2039 Q St
<br />Be. APT. NO.
<br />103a
<br />9f. ZIP CODE
<br />68503
<br />9g. INSIDE CITY LIMITS
<br />YES ©' NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married E Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Shields
<br />Vickie Hinkle 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />14a. INFORMANT -NAME
<br />Robert Shields
<br />14b. RELATIONSHIP TO DECEDENT
<br />Father
<br />15. METHOD OF DISPOSITION
<br />Burial [3 Donation
<br />0 Cremation 0 Entombment
<br />Q Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />February 26, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />CITY / TOWN
<br />Doniphan
<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 />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter tM chain of events- diseases, injuries, or complicatlone4hat 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 one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Hypertensive And Atherosclerotic Cardiovascular Disease
<br />IMMEDIATE CAUSE (Pinel
<br />4s4ase or condition-Mei/Ring
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, H b)
<br />eny,;Npding to the cause.fisted
<br />ort line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury thatinitiated
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />the events resulting in doth) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _. d)
<br />onset to death
<br />18. PARTII. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF. FEMALE:
<br />0 Not pregnsn within pest year
<br />Pregnantal time Of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If 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 />E Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />E YES ❑ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />E YES NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, att. (Specdfy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23e. TIME OF DEATH
<br />!3d To the best of ray knowledge, death occurred at the time, date and place
<br />end due to the causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YEs _❑ NO 0 PROBABLY E UNKNOWN
<br />STATE ZIP' CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 24, 2021
<br />24b. TIME OF DEATH
<br />Unknown
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 21, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />11:57 AAA .
<br />24e. On the basis of examination and/or Investigation, In my opinion death *Muffed at
<br />the time, date and place and due to the cause(s) stated. (Signature dad Title)
<br />Patrick F. Condon, Lancaster County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT GRANTED? .
<br />Not Applicable If 26a Is NO ° ❑ YES ID NO
<br />27. NAME, TITTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Patrick F. Condon, Lancaster County Attorney, 575 South 10th St., 4th Floor, Lincoln, Nebraska, 68508
<br />28a. REGISTRAR'S SIGNATURE
<br />`Rcr-ic. . 2.1>P
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 3, 2021
<br />i
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