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<br />1 ;< STATE OF NEBRASKA _ 0"700""
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<br />WHEN THIS COPY CARRIES THERAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPS OF THE 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 pF:ISSUANCE
<br />1/13/2022
<br />LINCOLN, NEBRASI(A
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 'r
<br />CERTIFICATE OF. DEATH
<br />1. DZCEDENT'S=NAME (First, Middle, Last, Suffix)
<br />Steven Leonard Toner
<br />2. SEX
<br />Male
<br />4. CI'1 a AND STATE OR TER
<br />Wahoo, Nebraska;:
<br />TORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sir: ADE - Last Birthday
<br />(Yrs.)
<br />61
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />21 1876.6
<br />3. DATE OF DEATH (Mo.. Day, Yr.
<br />December 29; 2021
<br />6. DATE OF BIRTH (Mo. Day, Yr.)
<br />i'. S>+fCIAL SECURITY NUMBER
<br />508 92.6731
<br />8b. FACTLITY•NAME (it not Institution, give street and number)
<br />1716 Roberta Avenue
<br />8c'CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 0$$43
<br />9a. RESIDENCE -STATE
<br />Nebraska..;
<br />Sd.STREET AND NUMSER
<br />1716 Roberta Aventie
<br />10a: MARITAL STATUS AT TIME OF DEATH [511 Married 0 Never Married
<br />Marriaffi but separated 0 Widowed 0 Divorced 0 Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />0 ER/Outpatient
<br />❑ POA.
<br />9b. COUNTY
<br />Hall
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Larry Toner
<br />13. Ev i tN:u SL ARMED
<br />(Yes, No, or Unk.) NO'
<br />FARCES? Glove dates of service 11 Yes.
<br />15. METHOD OF:DISPOS(11ON
<br />[ >Burial ❑Dona on
<br />IJ Grematioft d Entotiibment
<br />al . ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />February 26, 1960
<br />OTHER 0 Nursing Horne/LTC
<br />® Decedent's Homme
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Lisa Ann Heliwiq
<br />12. MQTHER'S-NAME (First,
<br />Rase ; .Ann> Reiff
<br />. ....... ............
<br />14a. INFORMANT -NAME
<br />Lisa Ann Toner
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a..;FUNIERAk;::i11QME NAME AND MAILING ADDRESS: (Street, City or Town, State}
<br />All Pathe Pt.ineral Home, 2929 S. Locust Street, Grand Island Nebraska for
<br />Other (SaeilfY). , .
<br />16b. LICENSE NO.
<br />9f. ZIP CODE
<br />68803
<br />pica Fao(Itty::..
<br />90INSIDECITY14611T$;.
<br />'.YES l .NO
<br />Suffix) 1f wife, give makien name
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP. TO D
<br />Spouse
<br />16c. DATE (Mor Day Yr)
<br />December 30, 2021
<br />CAUSE OF DEATH (See instructions and examples)
<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 additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Gastrointestinal stromal tumor
<br />innmgpIATE CAusit (p)nai
<br />dl00e er irontdien reseitlsg::<
<br />In, death)
<br />Sequentially Iist,donditIons,
<br />sny,.Iesdlfl to the cause iisted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />STATE
<br />Nebraska
<br />1Tb Zi::code;
<br />88801
<br />APPROXIMATE INTERVAL
<br />sotto LleafrY
<br />3Years<
<br />' onset to death':
<br />Ente die ONDBR1.Y1N6 GAUBE'
<br />(disease or it U(ythat initiatetI;
<br />resulting in death
<br />the events
<br />LAST
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />c)
<br />DUE TO OR ASA CONSEQUENCE OF:
<br />d)
<br />18.18...RARTILOTHEREIGNIFICANT CONDITIONS -Conditions contributing to the death but notres
<br />Hycier99061OK
<br />X20. IF FEMALE
<br />Not
<br />9001140 T4/119#9.94 Vffir
<br />I Teo44: tt at #title d(ditatIt
<br />❑
<br />Not firegnik but ptsgtiant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />iFltltnoy+n if t#fegnatltwifhin the past year
<br />22a gA rE OF Ifi IURY (INo:, bay, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homrwtde
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />onset **Eh
<br />underlying cause given In: PART I.
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />QYES; ONO
<br />22c. PLACE
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />22f :LOCATION"QE INJURY:> STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December29, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 30, 2021 05:29 AM
<br />21b, IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0. Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER' CONTACTED?'
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES : i NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLL�
<br />TO COMPLETE CAUSE OF DEATH?
<br />URY-At home, farm, street, factory, office building, Construction'
<br />23c. TIME OF DEATH
<br />Ta the bast of fl?y: knowledge,: death occurred at the time, date and place
<br />duetotfiarausa(s) stated, (Signature and Title):
<br />Chad Vieth,"MD
<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: PEAR ...
<br />2Aa. 0it the basis of examination ancuor investigation, in my opinion deatt t4GGsrced at
<br />tris rima,: date and place and due to the causes) stated. (Stgnatura Sat 1(e) 'I
<br />;5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN.OR TISSUE DONATION BEEN CONSIDERED?
<br />YES NO Q PROBABLY 0 UNKNOWN 0 YES ®NO
<br />T .,ME TITL :AND AbOREfb OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley#400, Box 9802, Grand Island, Nebraska, 68803"
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is :NO ID `EES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 9, 2022
<br />
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