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<br />WHEN; TTIEIS COPY :. CARRIES THE RAISED ,$EAL :OF THE STATE eilfF NEBRASKA,' iT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE CURT IAF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VIT
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF1SS(1r4NCE
<br />71512017
<br />LINCOLN, NEBRASKA
<br />20230008 0.
<br />STANLEY S. • • PER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMEN'F'OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, MR
<br />Rodney Lynn Shada
<br />Last, Suffix)
<br />C777AN(i STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fretnor(t, Nebraska
<br />7. SOCIAL.^.ECURITY NUMBER
<br />505.50-7497
<br />8a, AGE . iast.Birthday]. UNDER 1 YEAR
<br />(Yrs. • t1.* :.:DAYS
<br />71 •
<br />sb FACILITY NAME ((f not.Institutlon, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />9a. RESIDENCE4TATE`.:.;
<br />NeDfaS#a :...' ..:.;
<br />Bb. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />u.
<br />1323 Haggle Avenue
<br />1 tie• MARITAL STATUS AT TiME OF DEATH l Married 0 Never Married
<br />❑Married, bu* separated ❑ Widowed 0 Divorced 0 Unknown
<br />'s
<br />2
<br />11. FATHER'S -NAME (First Middle, Last, Suffix)
<br />George Moses Shada
<br />EVER IN U.S: ARMED:FORCES?
<br />(Yes, Ne , or Unk.) NO
<br />Give dates of service If Yes.
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c, CITY OR TOWN
<br />Grandisland
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MII
<br />3. DATE OF MATH (Mi
<br />June 25, 2017
<br />., Day, Yr.),
<br />8. DATE OF BIRTH (Me.,.Day Yr„)
<br />Octobe
<br />19,194
<br />OTHER ❑ Nursing Home/LTC ❑ Hospice Facdfity
<br />❑ Decedent's Home '.
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />Wb..NAME OP SPOUSE:{First, Middle, Last,
<br />Marcia Ann Christensen;'
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, give mai,
<br />12. MOTHER'S -NAME (First, Middle,
<br />Evelyn Lucille Munneke
<br />14a. INFORMANT -NAME.:
<br />Marcia Ann Shada €.
<br />9g. INSIDE CrrY titans
<br />® YES ❑ NO
<br />Maiden Surname)
<br />14b. RELATIONSHIP TODECEppeT';
<br />Spouse
<br />5. METHOD OF o(SPOSIT)O'N
<br />12)`9Uttai . .0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Aemoval ❑ OEteTt$pecify)
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a FUNEOL'tfams NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island; Nebraska
<br />19b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />r t. iwte,i eebekt . eients--igesaoes, Fy'w,as, er semelleatienedhat directly cosiest( tM S9nt1WDO'MDT MDT fits sueh es Cardiac arrest,
<br />raipirstory arrest sr ve triatiier fibrillation without showing the etiology. DO. NOT ABBit8vIATE Enter only one cause ton s line. Add additional lines f necessary;
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Pancreatic Cancer
<br />disease or condition resulting
<br />to death) i;. DUE TO,OR AS A CONSEQUENCE OF:;.
<br />seraaentialiy iiia coodwone it b)
<br />any leShcrt9.td the Cause Itsted ''
<br />18c. DATE (Mo. flair, Yr.)
<br />June 30, 2017"
<br />STATE
<br />Nebraska'
<br />17b. Zip Coda
<br />68801
<br />onset to death
<br />Years
<br />must tp tMafh.
<br />" "•
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE• C)
<br />Idiserte br injury fitat wow;
<br />e eretw Idem
<br />1" 0004 > DUE TO OR ASA CONSEQUENCE OF:
<br />LAST;: d)
<br />18. PART Ii. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying
<br />Malnutrition, Peptic Ulcer Disease, Prostate Cancer
<br />20 IF';FEMALE . a
<br />❑ : Plot ptagnanswlthu t poet year
<br />'❑ Pregnant at time of death
<br />N. of pfanaer but pregnant wlhln 42 days: of death
<br />Not'04(ina tt, bet pregneft 43 days to 1. year before death
<br />r-� U:.nknown if pregnant within the past year
<br />'El
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d1JURTAT.WORi{7'
<br />Y .❑)10
<br />21a. MANNER OF DEATH
<br />Natural `: 0 Nomlcide
<br />0 Accident 0 Pending Investigation
<br />❑Suleide ❑Geuid.notbedOteryained
<br />22b. TIME OF INJURY
<br />use given In PART L
<br />21y!l�.y IFTRANSPORTATION INJURY
<br />L_i Dnrer/Operator
<br />❑ Passenger
<br />QPedestrian
<br />ottnerispec fy)
<br />19. WAS MEDICAL EXAMINER
<br />O(t'CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFO
<br />❑ YES ®NO ,
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DSATH?.
<br />El YES . ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify) •
<br />DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />DATE OR fkiw:RTH (Mo., Day, Yr.)
<br />Jlrie 25, 2017
<br />CITY( OWN
<br />23c. TIME OF DEATH
<br />11:04 AM
<br />23b DATE SIGN (Mo., Day, Yr.)
<br />One 27, 2017
<br />/ 3"d,', l o the beat of.m knowledge, death occurred at the time, date and place
<br />ands tilts to tire causes) stated. (Signature and Title) -.
<br />DI] U&ECCINTRIBUTE;TOTHE DEATH?
<br />^` NO '❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jai C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />REGISTitAftS SfSNATURE ja,
<br />24a.
<br />TE
<br />STATE'
<br />SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />DEATH
<br />Zp
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, in my opinion death oCcgrrad':at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tate).
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN. CONSIDERED? 269- WAS CONSENT ORAN
<br />❑ YES
<br />NO Not Applicable If 26a is NO
<br />28b. DATE FILED BY REGISTRA
<br />June 28, 2017
<br />
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