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<br />frWEN 17IIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SRVICS, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />t?ATE OF!$SUAAr,..
<br />3/11/2022
<br />LINCOLN, NEBRASKA
<br />202204417
<br />1. D L NVS 1VAM& `tFfrsk MlddIe
<br />Richard. Mede Stewart
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />L)ncoln,N braska
<br />7 SOCIAL SECIIRIT'Y Null/mon
<br />605 8.13.1955
<br />8b. FACILITY -NAME Of not Institution, gibe street and number)
<br />Grand Island Regional Medical Center
<br />8c,: CITY OR: TDIAPI OF DE t rH (Incklde Zip Code)
<br />Mand Isl9lid S98£i3,
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />se..erEET Arts ueesR .:
<br />1407 Meadow Road.
<br />6a, AGE - Lath Sirthday.
<br />(Yrs.)
<br />64
<br />db UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />80. PLADE OF DEATH
<br />HOSPITAL ® InpaIenit
<br />0 ER/Outpatient
<br />p DOA
<br />DAYS
<br />HOURS
<br />MINS.
<br />22 03516
<br />3. DATE OF oEATH (MA f2AY Yr,.);,
<br />;February 2S$ 2022
<br />6 'DATE OF BIRTHIMo., Dao, Yr.)
<br />January 1.1998
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Ho
<br />❑ Other (specify)
<br />9b.`COUNTY
<br />Hall
<br />10a MARITAL:STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />1. FATHER'S -NAME (Fust, Middle, Last, Suffix)
<br />Merle Stewart
<br />13, EVER IN ti.S ARMED FORCES? Give,dates of service if Yes.
<br />(Yes, No, or Unit.) NO
<br />18 METHOD of wags),
<br />0 auttat ❑ Donafton .. t
<br />j j reniado � Entpntbmont
<br />[}'Removal ❑ 0:..;e(Specify)
<br />( Ky)
<br />9c. CITY OR TOWN
<br />Grand island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />88803
<br />1NSIG18 CITY) fOrita
<br />l >No
<br />10b. NAME OF SPOUSE (Ftrst, Middle, Last, Suf lx) If wife, give maiden matte
<br />Candace Ann Willey
<br />Maiden Sumeme)
<br />12. MOTHER S•NAME (First, Middle,
<br />Darlene Morse
<br />14a. INFORMANT -NAME
<br />Candace Ann Stewart
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17e. LIBERAL ROME NAME AND MA LING ADDRESS (Street, City or Town. State) ..
<br />.
<br />A Faiths Funeral'Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />CAUSE OF DEAT
<br />14b RELATIONSNIP TO DECEI
<br />Spouse
<br />H' (See Instruct rls and examples)
<br />15. PART I, Enter the chain of evont*..dlaesse*, injuries, or compllcatlans.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or venlrIcul rfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />R (Penal a)Acute respirator failure
<br />IMMB *14 OAti
<br />'.. daa9NN#e or C4ndltit4a reamain
<br />M
<br />Sequentially list conditions, 11
<br />any, Iestilhgtothejau*aliated
<br />Entet etelklea1tGYIN
<br />fillseatIWOr Injury:gl'st
<br />LAST
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b)Pneumonia
<br />APPROXIMATE PITERVAL
<br />to deatt7
<br />ort> a to death ..: .
<br />021 0/22 - 0
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />resultidtt is death
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />d)
<br />18. PARTI3 OTHP SIGNIHICANTCONDITIONS.Conditlons contributing to thedeath but notrds•
<br />u
<br />matignancy,:cOion..8ver ..
<br />Ilei p egnaet stthln Past yea
<br />#Pregnant attune attiaati► ::
<br />❑ Natptegneelr but pregnant wNdn 42 days of death
<br />❑ Not pregnant, butpregnant 43 issya to 1 year beforedeath
<br />❑ SMknown s nreegnantwiuun pie past year
<br />22e;tlATE OF INJURY
<br />Mo.>I.
<br />22d. INJURY AT WORK?
<br />OYER ONO
<br />22r: LocATiON OF t
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homidlde
<br />❑ Accldem 0 Pending Imrestlgaaon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At M
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />AIRY . STREET & NUMBER, APT.NO.
<br />e. DATE OFDEA1aH(Mo., Day ,.Yr.)
<br />February 26, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ig in the underlying cause given in PART 1. '
<br />21b, IF TRANSPORTATION INJURY
<br />❑ DoluseOperator
<br />Passenger
<br />0 Pedestrian
<br />o Other (Specify)
<br />19.WASMvI..A. LEXd
<br />OR C0 3NER. CON
<br />❑
<br />YES ® NO
<br />21c. WAS AN AU
<br />❑ YES -N
<br />21d. WERE AUTOP
<br />TO COMPLETE*
<br />❑ YEs
<br />e, farm, street, factory, office building, corns
<br />Oil
<br />GS AVAILABLE
<br />DEATH?
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:0Q PM
<br />23d Tc thele of My knoWtedge, death occurred at the time, date and place
<br />And %Bu W 1151::cauSets):stated. (Signature and Title)
<br />Jose Belo, APRN
<br />26. MD TOBACCO USE CONTRIBUTE TO. THE DEATH?
<br />1::3 YES ..a NO ❑ PROBABLY 0 UNKNOWN
<br />27. DME, TITLE AND AOOkils OP CERTIFIER (Type or Print
<br />Jose.Bajo, APRN, 3553 Prafrieview, Grand Island, Nebraska, 68803
<br />STATE
<br />24a., DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />ATH
<br />P
<br />DE
<br />24d. TIME PRONOUNCED QEAD:
<br />Oa the beets of examination andtor investigation, in my optnkat dN_ ,
<br />the tlmai'date and place and due to theycause(s) stated. (signature's
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ANO
<br />26b. WAS CONSENT empty?
<br />Not Applicable if 26a is NO YI«
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 8, 2022
<br />
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