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<br />.:1..WHEN3.:TOIST'.: COPY CARRIES THE RAISED SEAL OF THE :::STATE OF NEBRASKA, IT
<br />s
<br />„.:CER1TFflS THE DOCUMENT BELOW TO BE .:..A TRUE COPT ...OF THE ORIGINAL RECORD N
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />F!,,gC0flf;IS.9r. WHICHTHE LEGAL DEPOSITO. RTff.
<br />.FOR VAL.I;EC011DS
<br />202/0734'1
<br />DATE OPISBUANCE - H
<br />8/1 0/2020 . )674.44....1) 4
<br />SARAH BOHNENKAMP 411111'-i
<br />I!? ,
<br />II
<br />i
<br />LINCOLN, NEBRASICA
<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 .., 20 10327
<br />1.o*COOkNtOsiANIC(First,- Middle, 'Last, Suffix)
<br />Shawn;!Wiatley...,!Price
<br />4. OMANI) STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCIAL SEDURITY140MBER
<br />006-94-9234 -- •
<br />8b. FACILITY.NAMEItince Institution, give street and number)
<br />` Health St. Francis '•
<br />0okDrlyD.Dmymiottpf4.111!(ipolucifZip Code) !,
<br />Grand Island 68803
<br />,........
<br />9a. RE$iDENCESTATE
<br />Nebraska
<br />9d• STREET AND NUMBER
<br />1108 S Niirle
<br />9b. COUNTY
<br />Hall
<br />joe MARITALSTATUEAT TIME OF DEATH au Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />taet'airthday:
<br />(Yrs.)
<br />49
<br />Ms:ANDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATHIMBS.,,D**.a"41
<br />6. DATE OFBIPLIN!tMo.,Daya41;
<br />July 2, tall
<br />Ge. PLACE CSOexolu,:,
<br />HoeFit:TAt*DSjifn;Patiefit OTHER!0 Nursing Honte/LTC4'
<br />0 EK/Ou patient
<br />0 Decedent's Herne
<br />o DOA
<br />Other (Specify)
<br />Gd. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Ge. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />IhiES ONOi;
<br />...-
<br />lob. NAME OF SPOUSE (First, Middle Last Suffix) If wife give maiden name ••••••
<br />Kari Braun
<br />14. FATHER'S -NAME (First Midd a, Last, Suffix)
<br />John Price .
<br />12.!MOTHEIVS,NAME (First, Middle, Maiden Surname) ' !.;:.!!!!..!i;.•!..!1'!...i:::..N!,,,,,,,',.6.!:.=:.
<br />,. _ , ........... _ .....
<br />- !!..,:......... ............
<br />H!!!!!!--Sdeti.•:::::iyollmer
<br />4
<br />1
<br />EVER IN u.s, Aameo -FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 10/10/1989-10/08/1993
<br />14a. INFORMANT -NAME
<br />Kari Price
<br />14b, RELATIONSHIP TODECEDENT
<br />Spouse
<br />15. METHOD
<br />i!!!' 0131.441 0 Donation
<br />Eqretoatow:LJEn0IiibrneTt
<br />(Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />19e. DATE.(mo,,,Dey,
<br />July 28, 21;2c',V,'
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />• •
<br />Nebraska
<br />•
<br />41a. FUNERAL Nome NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street Grand Island. Nebraska
<br />068801.M -VM.
<br />CAUSE OF DEATH (See Instructions and examoles)
<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 addltIonat lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Mel Pancreatic Cancer
<br />disease or Cando -Ion moulting
<br />In dalatit
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list tondltIonii, if b)
<br />any, leading to the cause listed
<br />APPROXIMATE INTERVAL,.
<br />".!!!!!!!!,":",!!.!!!' •
<br />onset to death
<br />DUE TO i OR AS A CONSEQUENCE OF:
<br />Enter the
<br />(thatiaaaer injarylhatInitletee ,
<br />the events resulting In deadi) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />16. PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Nicotine Dependence
<br />20' If!..MIIAI.E:....! ,
<br />EI#6t#eCOPi91/Paat year/:
<br />,....,... ....... ' ' ,-
<br />.. ,.....,g 9 ,......,,..,•..•
<br />C*41...fr,..,!,=.ot......iiri.441.44,
<br />,...,. :
<br />..'...:....
<br />11.... MIN.: PM ii . but phagnent within 42 days of death
<br />,., pregnant, but pregnant 43 days tot
<br />......:........: .„.. 41/peass1thin the past yeti, , •
<br />..' laROth/OM ii F,wi' - year before death
<br />21a. MANNER OF DEATH
<br />[0 Natural Ej Homicide
<br />0 Accident E3 Pending Investigation
<br />0 Suic de 0 Could not be determined
<br />225 OATEOF)NAIRY(M*1D5y Yr)
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />•0 Passenger
<br />0 Pedestrian
<br />o Other (Specify)
<br />19. WAS MEDIDALEXAMINEB!, M.!
<br />OR C9RONERPONTAqT00?-..!!':.•!!!'i
<br />YES ig] NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES JNO
<br />21d. WERE AUTOPBY:F.INDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES E] No
<br />22c.13:4-AokpEiN4uay4tpoo,forrni•••••sreet, factory office buIlding constructiori...11B9,'!e#,!;B!//e,!//y!
<br />..• • •••:....„„„...:„.,•
<br />• • : : :••• •
<br />nil. INJURY AT WORK?
<br />YES 1:-.] NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f tOCM1ON OF INJURY STREET & NUMBER APT NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 26, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Auoustl0
<br />23c. TIME OF DEATH
<br />12'30 PM
<br />3d. Toth° bet Tiny knowledge, death occurred at the time, date and place
<br />and &tete/ha cause(s) stated. (signature and Title)
<br />Chad Vie h, MD
<br />2$. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />1:0 YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />8
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />2.44.]Pn the bests of examination and/or investigation, In my opinion tildiai4464.44
<br />11wome, date and place and due to the cause(s) Stated. (SmeetureasMINe)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES fia NO
<br />27:;,qAragoiTAANo!4opapiaa OF CERTIFIER (Type or Print
<br />'Chid
<br />Viett, IVID,'2116'W Faidley #400, Box 9802, Grand Island, NebtaSkat.,688oa
<br />Ma. REGISTRAR'S SIGNATURE
<br />2.."24-•01 84.
<br />WAS CONSEN
<br />Applicable if 26a1s NO
<br />Not
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />Auguet.10, 2020 11
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