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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EEA TRUE COPY OF TWE ORIGINAL RECORD ON FILE WITH THE NEBRASKA; DEPARTMENT OF HEALTH AND
<br />HUMAWSERVICES, VITA4 RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA 1'E OP ISSUANCE
<br />6/11/2022
<br />t INCOLN, NEBRASKA
<br />202208825
<br />SARAH BOHNENKAMP /
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />��llirnr , r r,lll,
<br />rrttL,;1Ir� ),0,,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />I. [?I«CEDENT 6) NAME (F)rst, Middle, Last,
<br />iaut Allan .Ouiseriberry
<br />Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />SOCIALSECURITY NUMBER
<br />60548'940
<br />Bb. FACILITY -NAME (If not institution, give street and number)
<br />1 Riverside Lodge, Inc.
<br />8c. CETY OR TOWN OF.TH (Include Zip Code)
<br />Grand Island 8881:1
<br />9a. ftE$TDENCE $TATE";;
<br />ebraska
<br />9d. STREET MW NUMBER
<br />404 Woodland Drive
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />ty
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />14. FATHER'S Nurse (First; Middle, Last - Suffix)
<br />Paul Quisenbsrry
<br />8a. AGE • Last:efrthday
<br />(Yrs.)
<br />99
<br />8b. :UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH s:
<br />HOSPITAL ❑ inpatient
<br />ERiou patient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />22 07867
<br />3. DATE DEATH Ma, pay, Y
<br />June 1, 2022 /,
<br />6. DATE OF BIRTH fMo., Gay,Yt.j
<br />December48,1::922....
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home }}
<br />E Other (Specify)ASSIS'I'EQ LIVING
<br />(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand island
<br />9e. APT. NO.
<br />49
<br />1Ob. NAME OF SPOUSE (First, Middle, Last,
<br />Minnie
<br />Perdew
<br />12. M'jTHER'S.NAME (First,
<br />Margaret Allan
<br />13 EVERtN US ARMED FORCES? Give dates of service if Yes. I 14a. INFORMANT -NAME
<br />(Yes, No or Unit.) No 1 Gary Quisenberry
<br />18. METHOD OF DISPOSITION
<br />..],f„&01000
<br />❑ Iltmaton
<br />ematioe ❑ Entomttment
<br />al r ❑Ot a Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18d. CEMETERY, CREMATORY OR OTHER LO "t.AT10N'`
<br />Wood River Cemetery
<br />17a FUNERAL HOME. NAME AND MAILING ADDRESS (Street, City or Town,$tate)
<br />At;fel Furfer'ild HAm ,1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1537
<br />9f. ZIP CODE
<br />68801
<br />f.lid$�IE t^.13'Y E3Ai1'tt;€
<br />CE: vEs p: No
<br />Suffix) If wife, give maiden manna
<br />Middle,
<br />CITY / TOWN
<br />Wood River
<br />CAUSE OF DEATH (See instructions and examples)
<br />IS, PART 4 EMer-tare Chain of Mins. -tiee see, injuries, or compiicatione.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 ane cause on a tine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />Iffin lATsc u Mod 'a) Coronary Artery Disease
<br />disease or ctnditiof reeUIthtg;
<br />in death)
<br />Sequentially net conditions
<br />any,Matting to the cause'.
<br />on title a
<br />14b. RELATIONSHIP To tomer
<br />Son
<br />160. DAT E(Mo Osy,.Yr.)
<br />June 4, 20:
<br />El181531,11141)1DEB1,148K8;411811
<br />(des:ai injruy:inat Ittttiatas
<br />the events resulting in death):,
<br />LAST
<br />DUE, TO, OR AS A CONSEQUENCE OF:
<br />b) Dementia
<br />Nebraska
<br />1Th 2lpCoda :
<br />1.'48(191.
<br />APPROXIMATE INTERVAL`
<br />onsettC :
<br />Years ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Chronic Diastolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Pulmonary Fibrosis
<br />18 p 41RT II OTI fiR SlfitQIRCANT CONDITIONS -Conditions contributing to the death but not resulting in qts tdlderlying cause given in
<br />Sinus Pauseis, Frequent Fans Hospice
<br />20. IF; FEMALE;
<br />�- f NOt tmpnanf wiadn gest year
<br />Pregnant altime
<br />ar death.:
<br />otleregnas#; but pregnant within 42 days of death
<br />Not pregnant, but pregnant 48 days to 1 year before death
<br />Unknown If.pregnarawimin the past year
<br />22a. DATE OF INJURY (Mo;;;Day, Yr.)
<br />22d, INJURY AT WORK?
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ AccldeM 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b IF TRANSPORTATION INJURY
<br />driver/operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />Years
<br />onset to death
<br />Years
<br />PART I. 19 WAS MEDIfK`AL;I9xAtAINER ::
<br />OR CORONSicONTAOTSCT'
<br />❑ Yes ®NO
<br />21c. WAS AN AUTOFSY, PERFORMED?
<br />vas 1Z1,146.
<br />21d. WERE AUTOS � Gs A1:
<br />TO COMPLETE CAUSE OF DEATH'
<br />❑ YES D.. wo
<br />22c. PLACE OF INJURY.At hone, fatm, street, factory, office building, construction site, etc (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF minty -STREET & NUMBER, APT.NO. CITYITQWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 1, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 6,x022 04:29 AM
<br />88d Tog* woo my knowledge, death occurred at the time, date and place
<br />MI4 OS 10 lila taunts) stated. (Signature and Tide)
<br />Michael A. Donner, MD
<br />STATE
<br />25. Dip TOBACG,O USE CONTRIBUTE TO THE DEATH?
<br />VE$ NO CJ'FROBASLY 0 UNKNOWN
<br />Ni di , YI ANOAL)* LESS OP CERTIFIER (Type or Print
<br />Mitahael A Doflner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />s
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2413. TIME OF"DEATP
<br />24d. TIME PRO140)14 :ED,DEAD.
<br />t>,
<br />!M. Oru the basis of examination endear investigation, le my ophrion dRadt:i.A 11
<br />Meths., flare and place and due to the cause(a).atated.(Sl gttua arttl'r e)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 11 NO
<br />Ot-4,1 t % rc kea-rs
<br />26b. WAS CONSENT t
<br />Not Applicable if 20a Is
<br />28b. DATE FILED BY REGISTRAR (Me., Day, lset)
<br />June 6, 2022
<br />CO
<br />
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