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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERT/PIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINALRECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN'SERVWCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE
<br />ISSUANCE
<br />2/10/2022 2/1 )/2022
<br />LINCOLN, NEBRASKA
<br />202204753 I'
<br />t
<br />Ir:
<br />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 />1. D 9ERENt`S NAME (First, Middle, Last, Suffix)
<br />ions Lee Cooper Reyes
<br />C)TY ANI) STATE QR TERRITORY,; OR FOREIGN COUNTRY OF BIRTH WAGE • Last Igirthday 5bi UNDER 1 YEAR
<br />(Yrs.)
<br />Grand island Nebraska
<br />. SOCIALSB;CURITY:NUMBER
<br />5071868
<br />b. fAClt.(TY=NAME (If not Instkutlon, give street and number)
<br />421 E. 1st St
<br />8c:. CITY OR TOWN t)F DLtATH (Include Zip Code)
<br />viand leland 688f3'
<br />.8 9a. RESIDENCE -STATE
<br />ffi
<br />Nebraska
<br />9d. STREET AMID NUi1tIs�R
<br />421 E 'lst',St
<br />2. SEX
<br />Female
<br />MOS. I DAYS
<br />57
<br />8a. PLACE OF:DEATH
<br />HOSPITAL ..0 Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />I9b. COUNTY
<br />Hall
<br />10a.:MNARITAL$TATtUSATTIME OF DEATH 0 Married 0 Never Married
<br />0 Marrted, but separated _® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'
<br />Layoff*
<br />ofrf!e'
<br />AME (PIbst;=
<br />1NOIfe ;:
<br />Mid e, Last,
<br />Suffix)
<br />I9c. CITY OR TOWN
<br />Grand Island
<br />18d. COUNTY OF DEATH
<br />Hall
<br />6c. UNDER 1 DAY
<br />HOURS I MINS.
<br />3. DATE OF DEA')1t:(Mo. O0;*
<br />January 23, 2022
<br />8 DATE OF BIRTff'(Mo., pay, Yr;j
<br />October 1 :(914:+
<br />OTHER ❑ NBrsing 11ofII<C
<br />Ea Decedent's Home
<br />0 Other (Specify)
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />PEA G 1Mi7E',
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mal
<br />Mark Reyes
<br />12. MOTHER'S -NAME (First, Middle,
<br />Jeanie Cooper Evers
<br />13'EVERRINU.$ ARMED FORCES? Give dates of service if Yes. 14a.INFORMANT-MAME
<br />(Yes, No, or Link.) No .!- Laramie Reyes
<br />45. METHOD OF DISP08IT ON
<br />Burial ❑ 00na Non
<br />1Creittat*Rn ❑,Entombment
<br />❑' Renrtrval > ❑Other{Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />l16b. LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERALNOME NAME AND MA LING ADDRESS (Street, City or Town, State}
<br />AttFattheriinerattilome, 2929 S. Locust Street, Grand Island,; Nebraska
<br />AT ee J rtr .. i`•ns and -xa
<br />14b. RELATION$FNP TO ••E SDENT::
<br />DAD/111W
<br />18c. DAM( lq, Day,Yr
<br />January
<br />gTA'
<br />rsska
<br />PART 1. Ender the chats ore cots• •diseases, injuries, or complications4hat directly` caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />aaepkMory arrest, or ventricular flbrllation without showing tris etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATRCAU (Float a) malignant glioblastoma multiforme
<br />dlB4psa Or nondtton *hitting
<br />Sequentially list conditions. If b)
<br />am. Ieading to the cause lisp `.
<br />orliriea.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, QR AS A CONSEQUENCE OF:
<br />Eetiethe thetift tYiNQ CAAtISE ..
<br />(disaaeeorh�u}tthstInaht*1 ':
<br />18 PARTR. dTHER Stt#NtFJCANT CONDITIONS -Conditions contributing to the death but ntit resuttingan the underlying cause given In PART 1.
<br />20. (F FEMALE,?
<br />Ndt ategnant wfMn pati j4,..
<br />Pr.W+amat tlmte of death
<br />cir,L, bbut
<br />utpregluotwithin42daysofdeaysofdeathath
<br />pregnant 43 days to t year before death
<br />"lipkrfown itpngnant V+istn`dre past year
<br />22& DATE OI INJURY (M. ; Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />o Accident 0 Pending Imeetigetion
<br />O Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />DVVerlOperator
<br />© Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEtR4"311,.-$JfANfiN$ir
<br />OR cORoNEWOONTAOttaln
<br />❑ YES' ® NO
<br />21c. WAS/
<br />❑ YES
<br />21d. WERE AUTOPSY MiGs AVAILABLE,:
<br />TO COMPLETE CAUSEOP'DEATH?
<br />OYES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction siterite (Spy
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJURY:':: STREET & NUMBER, APT.NO.
<br />PATE OF DEATH. (Mo., Day, Yr.)
<br />January 23, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Januar? 27s 2022
<br />CITYJTOWN>
<br />23c. TIME OF DEATH
<br />10:15 PM
<br />211
<br />g
<br />sd m tee bp# ,14fr artowtedge, death occurred at the time, date and place
<br />4Nd titre tO tile'aaittse(a) stated. (Signature and Title)
<br />Kenneth Vettel, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD...
<br />/4e. On the baste of examination and/or investigation; hi my opklkan'Ifeattl Occurre(at
<br />:Ute tree, date and place and due to the cauee(s) staff. (8I atilt Title)
<br />26 DID TABACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 4Q NEI PROBABLY::.:❑ UNKNOWN
<br />N ME, 1iTE E.. AND ADDRESS OF CERTIFIER (Type or Print
<br />Kenneth ettel, M(), 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28a. HAS ORGAN
<br />❑ YES
<br />OR TISSUE DONATION BEEN CONSIDERED?
<br />ANO
<br />4-111
<br />?r? 'afryz�
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicableif 28a Is NO ," ] ] YES'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 6, 2022
<br />
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