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<br />STATE OF NEBRASKA
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<br />V . rEN :'PHIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />8E A TRUE COPY OP Ti(E ORIGINAL RECORD ON FILE WITH THE NEBRASM DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />04TE QFPSSPJANCE
<br />0/24/2.022
<br />202207998
<br />DENT 'NAME (Fi'Fst, . Middle,
<br />Virgti`tia Martie.. Hickey
<br />)0-4H' CA
<br />SARAH BOHNENKAMP I
<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 />Last, Suffix)
<br />4. CITYANo STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Anselmo, Nelbraska
<br />CIALSECVRITY NUMBER
<br />-3603
<br />Sb. FACILITY -NAME (if not Institution, give street and number)
<br />S. Grand Island Country House, L.L.C.
<br />8c C1TY OR TIENN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />DENCE-STATE
<br />raska
<br />90. COUNTY
<br />Hall
<br />5a.'AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER I DAY
<br />MOS.
<br />DAYS
<br />80, PLACE OF DEATH
<br />HOSPITAL, ❑.inpatient
<br />❑ ER/Ou patient
<br />Q;924:
<br />MR/REST AND NUMBER
<br />115 Ast OICI Ct.,
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated. ffI WIdowed 0 Divorced 0 Unknown
<br />9 F tTHHR BdiIAME (Fire t; , . Middle, Last Suffix)
<br />Arthur . Fd yard Kinlsh
<br />1 13.`EVER IN U8 ikii.ARMED FORCES? Give dates of service If Yes.
<br />8 (Yes, No, or Unit.) No
<br />8. METHOD OF DISP.OSIT�N
<br />Burial 0 Dont on ,
<br />p Crematksn ❑ Entombment
<br />Removal " CI Other, (Specify)
<br />9c. CITY OR TOWN
<br />Alda
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH{M+o.r
<br />October 122'.
<br />8. DATE OF'B(Rrfi'(Mo, Day,`T)
<br />July 24,1942
<br />OTHER 0 Nursing Home/LTC'
<br />0 Decedent's Home
<br />I Other (Specfty)ASSISTED LIVING
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />lie. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />iNsioa CITY1; Mi' s
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nates
<br />Michael Wayne Hickey
<br />14a. INFORMANT -NAME
<br />Kelli Michele Plihal
<br />18a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />12. MOTHER'S -NAME (First, Middle,
<br />Lily Barbara Weinman
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Anselm's Cemetery
<br />17a.: UNERAL:HOMENAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral I'%me, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Anselmo
<br />CAUSE OF DEATH (See instructIone and ex moles)
<br />Maiden Surnam
<br />14b. RELATIONSHIP TO DECEDENT,
<br />Daughter
<br />16c. DATE (Mo , Day,:Yr )
<br />October:24,.2022
<br />14. PART I. Enter the chain Of ev er-diseases, Injuries, or complicetions4het 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 />IMMEDIATECAus6 (Ruts a) Metastatic lung cancer
<br />theorise or Condition Marking
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />entially list Conditions,
<br />leading to ttlei caese'asted'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />thetSIDERLYINGCAUSE C)
<br />'S (disuse or injlny that intttined
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />iRTR OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death
<br />IFFEMALE
<br />tintstdni
<br />plsgnant, but i ngeantwahin 42 days of death
<br />❑ Not pregnant, but pregnald 43 days to 1 year before death
<br />yg�� ❑ ;un even gnant, Mme wet year
<br />tt 22a,DATEOFINJURY(MoDay, Yr.)
<br />JURY AT WORK
<br />YES O NO
<br />LOCATION OF INJURY := STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homleide
<br />o Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />STATE
<br />Nebraska
<br />RTD Zip Code P
<br />68801; '.
<br />t not.:suiting in the Underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October. 16, 2022
<br />216. IF TRANSPORTATION
<br />Ej Driver/Operator
<br />.0 Passenger
<br />❑ Pedestrian
<br />o Other (Specify)
<br />INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER'CONTAC . 0'?
<br />❑ YES®NO
<br />21c. WAS AN AUTOPSY PBRFoRMPDT
<br />❑,YES rape...:.
<br />21d. WERE AUTOPSY FINDINGS AVAK A
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />NJURY-At home, farm, Street, factory, office building, construction site, gtc;
<br />CITYROWR
<br />236 DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 17 2022 04:48 PM
<br />W.To;#w eearefoiy.knowledge, death occurred at the time, date and place
<br />and due to the;cause(s) stated. (Signature and Title)
<br />Chad Vieth, MD.
<br />DID TOBACCO USE CONTRIBUTE iTO THE DEATH?
<br />YES :O NQ ❑ PROBABLY ® UNKNOWN
<br />S
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED, DEAD ,„
<br />24e. bathe basis of examination and/or Investigation, In my opinion death ce sprredat:
<br />• •ie lime, date and place and due to the cause(s) stated. (Signature eargltle)
<br />28a. HAS ORGAN OR TISSUEDONATION
<br />0 YES
<br />BEEN CONSIDERED?
<br />2T HAME,T1TIaEASO ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />ac -44.17 gstotaLeenkoz-nez.-
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ;1 YES$
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 20, 2022
<br />
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