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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF 7`HE 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 />DATE :OFtSSVANCE
<br />101612022
<br />UNCOLN, NEBRASKA
<br />61144,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />g
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />f. DECEDENTS AME 4146t, Middle, Last, Suffix)
<br />James Michraei ,Ryan Jr
<br />4. CITY:AND STATE OR TERftITORY,'OR FOREIGN COUNTRY OF BIRTH
<br />Greeley, Nebraska
<br />9. SOCIAL SEBtl hitt' WUMes
<br />".06.62 14th
<br />8b. FACILITY -NAME (Minot Institution, give street and number)
<br />Tiffany Square Care Center
<br />6o,'GfTY ORTOLEId 43F,PEATillinslucle Zip Code)
<br />•
<br />• Grand Islas d 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />lyd. SIREET.A ICsNUMBAR
<br />2 16 We ..17th Stmt
<br />9b. COUNTY
<br />Hall
<br />Sit. AGE - Last Birthday
<br />(Yrs.)
<br />77 :>
<br />5b. UNDER 1 YEAR
<br />2, SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL] (npat4ent
<br />❑ ER/Outpatlent
<br />E] DOA
<br />10a. MARITAL :STATUS .AT TIME OF DEATH ® Married 0 Never Married
<br />[]Married, bid :seperated;®Widowed ❑ Divorced ❑ Unknown
<br />11. PATHPA's. lAM1. tFfitt, ' Middle, Last, Suffix)
<br />Jamey Michael Ryan Sr
<br />13. EVER IN U:S, ARMED FORCES? Give dates of service If Yea
<br />(Yes, No, or.tlnk,) Yes 1964-1966
<br />76, NIETH9D OF DISP9$ITKaN
<br />Burw Donation. , ,
<br />CramaUon Enttt r
<br />❑'Removal"]Other(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEA't'tt.tllo
<br />Septembet30,.2022:'.
<br />6. -DATE OF BIRTH (Mo„'
<br />E7ecember 20, :1944
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />floaplec Fe .1tY
<br />0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden parse
<br />Mary Ann Dutcher
<br />CITY tl
<br />112. MOTHER'S -NAME (First,Middle, Maiden Sumama)
<br />Madeline Mc Carthv
<br />14a. INFORM ANT -NAME
<br />Mary Ann Ryan
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />172 FUNERAL HOME NAs+lg"AIW MAILING ADDRESS iStreet, City or Town State)
<br />1' J Finn & Sons Mortuary, Branch of Ord Memorial Chapel, 1005 N 28th Box 230, Orr/;; Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon•
<br />14b. RELATION
<br />Wife
<br />16c. DATE(I
<br />OetCtber
<br />CAUSE OF DEATH'(Sea:irtstructfona and examples)
<br />18. PART I, Enter theeltsln��.dtAaates, t junes,'or compllcationsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory street, or vernacular Mitigation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />iMMEDIATE,CAUSE:
<br />MulljpEOiAT#CAU>;B#Finet a)Chconic Obstructive Pulmonary Disease•
<br />dieeeee er aondl inn r etusng.; ...
<br />In deride
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially listconditions, If :. b)
<br />any,.ieatgrty to the cause its tg
<br />bnlinca ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entert a.uNOVILY. llf SEC)..
<br />(dlsrbr injutythat inidated
<br />the *Weds resulting*
<br />death) DUE TC
<br />LAST d-
<br />DENT
<br />2122
<br />STATE
<br />Nebraska
<br />18562 .
<br />tri ZtF
<br />APPROXIMATE INTERVAL
<br />°tacos death:
<br />Molal$
<br />onset:fx
<br />18 PART II OTItER!IGN#FICANT CONDITIONS -Conditions contributing to the death
<br />congestiYe heart faittee, chronic kidney disease, hypertension
<br />24, IF.. EMALEr: .
<br />Nat
<br />❑ pregnaN wain•pa
<br />Pregtt8nt at tlms of daata
<br />❑ }Vat#tigneaL lana Dragnant wNhin 42 days or death
<br />❑ Na4pragnam,butpregnanl4&tlaysto1yearbeforedeath
<br />❑ Unknown 11 pregnant dthin the pat year
<br />22aimyreOFIAiJURY (Ma. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f ;LO ATIDNOE Ind
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homiest.
<br />❑ Aceidem 0 PentIMe InvaaagaNen
<br />0 Suicide 0 Could not be determined
<br />not resulting Ib the uhderlying cause given in PART i.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />OttvarfOperator
<br />El Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />.
<br />49. WAS M DICAL XAMIfdEE .
<br />OR OONTACTaD7-
<br />❑ YES gj NO,
<br />21c. WAS. AN AUT
<br />❑ YES
<br />21d. WERE AUTOPSY ENDINGS AVAILABLE
<br />TO COMPLETE ' 0 DEATH?
<br />0 YES tJ NO
<br />22c. PLACE, OF INJ4URV.At home, farm, street, factory, office building, const
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />I1RY«STREET & NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />September 30, 2022
<br />CITY/TOWN
<br />23b. DATE StONED (Mo., Day, Yr.)
<br />C�c#�bI>sf 3, 2D22
<br />Tdjeha,bpatormyoowiedge, death occurred at the time, date and place
<br />mtd dtre to tits cause(!) Stated. (Signature and Title)
<br />Chad Vieth, MD
<br />26. DID TO. ACGti v
<br />Q YES O.NO
<br />23c. TIME OF DEATH
<br />08:35 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. Tltti
<br />Ion SI
<br />40.4
<br />:ATE
<br />ZIP CODE
<br />24d'TIME PRONOUNCED:.DEAD _;::,
<br />24e. Olt the bssis:of examination and/or investigation, In my opbdon oath=udder
<br />the ttme, date and place and due to the "cause(s) stated. (Slgttaturesdt 19Ne;
<br />SE CONTRIBUTE TO THE DEATH?
<br />0 PROBABLY ® UNKNOWN
<br />2Sr. NAME,:mLE:MDAppRES8 OF CERTIFIER (Type or Print
<br />Chad Viettt;.MD,'2116 W Faidiey #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRARIfSIGNATURE
<br />26a. HAS ORGAN OR TISSUE, DONATION BEEN CONSIDERED?
<br />❑ YES au NO
<br />4J .8.44-"Lzeikei
<br />26b. WAS CONSENT GR
<br />Not Applicable M 26a Is NO
<br />28b. DATE FILED BY
<br />October 4, 2022
<br />y, Yr.)
<br />
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