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i.? la$�Ifsr IilBdl I fit ad+ f�)) c tmooltr I ziwzm l (t Ie 2dld x v4ttft1llj'(f,Nttnu 6k61Y/Aes n ntelB6�'Iftitenf w%tttyin as,tuotw, AWNP tOciaUlt fiaSiGsx46 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 9/13/2021 LINCOLN, NEBRASKA 202200084 • , ,t'ith 154 0,zaket on_ SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 11528 1. DECEDENTS.NAME (First, Middle, Last, Suffix) Steven Timothy Shelton 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 2. SEX Male 3. DATE OF DEATH (Mo., L1ay, Yr,) August 29, 2021 5a. AGE - Last Birthday (Yrs.) 65 5b. UNDER 1 YEAR Sc. UNDER 1 DAY MOS. DAYS HOURS MINS. 8. DATE OF BIRTH (Mo., 7. SOCIAL SECURITY' NUMBER 507-80-9132 8b.'FACILITY-NAME (II not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL El Inpatient 0 ER/Outpatient 0 DOA ay, Yr.) September 14, 1955 OTHER ❑ Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Grand Island 68803 Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island Hospice Facility 9d. STREET AND NUMBER 3417 Andrew Ave 11 9e. APT. NO. 9f. ZIP CODE 68801 9g.r�INSIDE CITY LIMITS NI YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sheryl Helzer 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Stanley Shelton ` Shirley Howland 13. EVER IN Ut8. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME Sheryl Shelton 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment 0 Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) September 3, 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Cemetery Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) NI Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter the chain of events- die , Injuries, or complications -that 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)aspiration pneumonia 'O N at IMMEDIATE CAUSE (Final disease or Condition resulting In death) Sequentially Ilst conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (chemise -Or injury that -initiated the events resulting In death) LAST APPROXIMATE INTERVAL onset to death Weeks DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) onset to 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. metastatic lung cancer, Brain metastasis, type 2 diabetes mellitus, stroke 20. IF. FEMALE: ❑ Not;pregnant within past year 0 Pregnant at time of seats 0 Not pregnant, but pregnant within 42 days of death ❑ 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? OYES ONO 21a. MANNER OF DEATH E Natural ❑ Homicide 0 Accident 0 Pending Investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) onset to death 19. WAS MEDICAL EXAMINER 'I OR CORONER CONTACTED? ❑ YES ENO 21c. WAS AN AUTOPSY PERFORMED? ❑YES ENO 21d. WERE AUTOPSY -FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ONO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. zz 0 23a. DATE OF DEATH (Mo., Day, Yr.) August 29, 2021 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) September 1, 2021 23c. TIME OF DEATH 03:26 PM 23d. To tale best of my knowledge, death occurred at the time, date and place end dus to the cause(s) stated. (Signature and Title) Vinay K. Singh, MD 25. DID TOBACCOUSE CONTRIBUTE TO THE DEATH? 0 YES ] NO 0 PROBABLY E UNKNOWN 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 and/or investigation, In my opinion death occurred et the time, date and place and due to the cause(s) stated. (Signature and Title) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Vinay I( Singh, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE Jac/ .2.11 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 2, 2021 i