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<br />STATE OF NEBRASKA
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<br />WHEN 1- KISS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />PAT EOF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />20220659.7
<br />irk, fir?
<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 "::DECEDENT'S -NAME €(First Middle, Last, Suffix)
<br />Raylt10i1
<br />40hr1 Michalski
<br />4: CITYAND;STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ravenna+ Nebraska
<br />7 SOC#AL. SECUR TY NUMBER
<br />505-44.:2:?83
<br />86 FACILITY -NAME (If not Institution, give street and number)
<br />Good.: Samaritan :Soclety-Grand Island Village
<br />8c CITYO,t7.0wN OF DEATH (Include Zip Code)
<br />' Grand island 68803
<br />11,1
<br />A
<br />9a. RESIDENCE -STATE
<br />Nebraska.
<br />9d:STREET; }t)D NttMBER
<br />918E PhOeniX Avt
<br />10a MARITAL
<br />OM `.
<br />9b. COUNTY
<br />Hall
<br />WAGE - Last Birthday
<br />(Yrs.)
<br />86
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3.1 DATE OF biA11i:.fiJNp
<br />July 20, 2€)22.
<br />6. DATE OF aikm (Mo.,
<br />June 15+1938:;°
<br />Pa. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER /:1 Nursing Home/LTC
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 DOA
<br />US AT TIME OF DEATH [2] Married 0 Never Married
<br />operated 0 Widowed :❑ Divorced 0 Unknown
<br />11") ATHER&:NAME (First, Middle,• Last, Suffix)
<br />Leo F :.Ml l'i l lei
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Other (Spfy)•....,..
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />r. 8g fi1181p$L;IT
<br />YES
<br />10b. NAME OP SPOUSE (First, ; Middle, Last, Suffix) if wife, give maiden name
<br />Sharon Hansen
<br />13., EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yea, No, or Unk.) Yes 01/09/1956-01/08/1960
<br />15. METNOD QF DISPQSrnON
<br />Burial ❑Donation
<br />Cremat on 0 Entombment
<br />QRsmgvite:` ]Other (Specify)
<br />14a. INFORMANT•NAME
<br />Sharon Michalski
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />12. MOTHER'S -NAME (First, Middle,
<br />'ackla A Slobaszewski
<br />16b. LICENSE NO.
<br />1092
<br />18d. CEMETERY, CREMATORY OR 0TI4ER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />.HOUIVEM. fLineral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />UMETS
<br />C:1- No
<br />14b. RELATIONEE4IP TLS DECEDENT
<br />Spouse
<br />16a. DA' E {Mo Oay. Yr )
<br />August t 202:..
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />• IMMEDIATE CAUSE:
<br />IMMEDIATEGAUsE(Finer a) Progressive supranuclear palsy
<br />11)405ee hrconditlon resulting
<br />In tlasthl.
<br />Seauentleity tet conditions, If
<br />any, leading to the ceuseaHeted
<br />on:tine a;:
<br />B/tpi the UNCERi YI/IS t AUSE
<br />(disease or Illjtitplhaf itlia9ted
<br />the events resulting in death)
<br />LAST
<br />11i ;+PART li."$
<br />Darnell#t
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ER 81C#4IFICANT CONDITION
<br />APPROXIMATE INTERVAL
<br />onsat to duadt.... ...::.. '
<br />1
<br />Yetitgir
<br />onditions contributing to tho.death butlOt re40)tingin
<br />20.:IF PF -MALE
<br />a Net ftraghwrtfl1tMn pesyear
<br />Pregnatltptttmatfdeadi
<br />Nbtpregr , bfdplagflast within 42 days of death a
<br />❑ Not pregtlan ,but pregnant 43,days to t year before death
<br />❑ 4pknowd/pragnaat> Itotet,atyear
<br />2", $t; DATA OIr INJ!)tY (ilio ; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES ❑ N0
<br />21a. MANNER OF DEATH
<br />Natural 0 i{omlcide
<br />❑ Accident ❑ Fending invastigetion
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />underlying cause given In P
<br />Ti.
<br />21b. IF TRANSPORTATION INJURY
<br />-0 Driver/Operator
<br />CI Passenger
<br />❑ Pedestrian
<br />El Other (Specify)
<br />19. WAS Mdei At. EXAMINER'
<br />OR coa0(I(�ER ACTED?
<br />❑ vas} NO
<br />21c. WAS AN AUTOPSY.
<br />❑YES �.,.
<br />21d. WERE AUTOPSYFI A>tA1LABt 4
<br />TO CQMRL(zTE @ i tt
<br />•❑ YES.. -Ey
<br />22c. PLACE OF )NJURY•At hotne, farm, street, factory, office building, c
<br />22e DESCRIBE HOW INJURY OCCURRED
<br />22f` LOCATIONS OF iNJURY STREET 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 20, 2022
<br />CITY/TOWN
<br />23b DATE SIGNED (Mo., Day, Yr) 23c. TIME OF DEATH
<br />&eat 4f t14y knowledge, death occurred at the time, date and place
<br />and dee tS tits else(,) stated. (Signature and Title)
<br />Richard Fruehlinb MD
<br />28. DID TOBACCO USE: CONTRIBUTE TO THE DEATH?
<br />❑ YES =1a} NO ""❑ PROBABLY 0 UNKNOWN
<br />2?, NAME, TtT#:E AND ADI REss OF CERTIFIER (Type or Print
<br />Richard ruehiing, MD, 3563 Prairieview St Ste 300, Grand Island, Nebraska, 68803
<br />Jr
<br />24s..0a the Casts of examination and/or Investigagan, hi my opIniwt d880424
<br />the thne,date and place and due to the cause(,) stated (aignatwe and."
<br />STATE
<br />r;1 r
<br />910 020,4
<br />2Eta. DATE SIGNED (Mo., Day, Ye.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TIME Of DEATH
<br />24d. TIME PRONQI
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES U4) NO
<br />26b. WAS CONSENT GRAMTED? `:
<br />Not.Appllceble If 28a Is NO ..0 V#:$
<br />28b. DATE FILED BY --_
<br />August 1, 2022
<br />
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