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<br />- STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />E A` TRUE COI , OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SER VICES. VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />PATE OOISSUANCE
<br />7/8/2022
<br />INCOLN, NEBRASKA
<br />/ Fr
<br />.IGf',4a/i !"..)f -dr:_xeIk-ttraf _
<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
<br />CERTIFICATE OF DEATH
<br />1. D.EOEOENTSAAME (Hist, Middle, Last, Suffix)
<br />Alfred Raymond Kuszak
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, :Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />505-5840856
<br />6a. AGE • Last Birthday :
<br />(Yrs.)
<br />77
<br />23
<br />ee'
<br />v;.
<br />is
<br />ri
<br />8b. FACILITY -NAME (if not institution, give street and number)
<br />Grand Island Repianal Medical Center
<br />8c. 011'Y DR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Jd..STREET.AH£1 NUMBEE .
<br />212 COmmanche Avenue:.
<br />6b.'UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL j Inpatient OTHER 0 Nursing Hone/LTC
<br />DAYS
<br />HOURS
<br />MINS.
<br />22 09087
<br />3..DATE OF DEATH IMO., Day, Y;:)
<br />June 22,'2022.. -!
<br />6. DATE OF BIRTH (Mo., Day,
<br />November 30, ;1944
<br />0 ER/Ou patient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT'TIME OF DEATH ® Married 0 Never Married
<br />0 Marriad, 134.20 id QWIdowed 0 Divorced 0 Unknown
<br />11. FATHER'S•NAME {First, Middle, Last,
<br />Paul K szalt
<br />Suffix)
<br />13..•1. FAU.St ARMED'FORCES? Give dates of service if Yes.
<br />(Vas, No, or Unk.) No
<br />16.'METHOD OF. DISPOSITION
<br />� Burrral ,] tlonat on
<br />Q;Cremation
<br />.Entombment
<br />❑Removal CI Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />*spice Fae:ifity
<br />91. ZIP CODE
<br />68803
<br />&g (NS}QE CITYI-LtIMITS
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Joy Lynn Barnes
<br />14a. INFORMANT -NAME
<br />Joy Lynn Kuszak
<br />16a• EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />12. MOTHER'S -NAME (First,
<br />Dorothea Engel
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a.:FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Ai'Faithsuneral )-tome, 2929 $: Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />Middle, Maiden Surname
<br />CITY / TOWN
<br />Grand Island,
<br />14b. RELATIONSHIP TO DECEDENT'
<br />SPOUSE)
<br />16c. DATE (Mo., Day, Yr.)
<br />July 1, 2022
<br />^STATE
<br />Nebraska
<br />17b, ZipGode
<br />fl8$fl1
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART 1. Enter the chain of events- -diseases, Injuries, orcomplications-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 if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEAIATE CAUSE (Filtai:
<br />dise$ge or SendhiOn resuktrig..
<br />In death)...DUE T0, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions ifi.{. b) Metastatic rectal cancer
<br />any, 144409 to 1115 reuse No0/
<br />a/Failure to thrive
<br />DUE 70, OR AS A CONSEQUENCE OF:.
<br />Enf4r1het4NDERLIIN0CAUSEC)
<br />(disease orinluiythatinitiated
<br />re eventsresultingi tit)
<br />sol,
<br />UE T0, OR AS A CONSEQUENCE OF:
<br />)
<br />18 T?RRT it OTHER S1GNi
<br />ANT
<br />APPROXIMATE INTERVAL
<br />onset tOiEeattl <'
<br />WeeltS
<br />onset to death
<br />4'!Months
<br />NDITIONS-Cohdit(ons contributing to the death but natresu(ting ltt fila underlying cause given In PART I.
<br />40.�-'IF;FEMALE:
<br />0 Nat 00090645a tthtg pant year
<br />Brregnattt at tints df daatii
<br />regnant but pregnam within 42 days of,lead,
<br />0 Notp
<br />0 Not Pregnant„ but pregnels 4a days to i year before deem
<br />.fl :unknown If preynadt within the past year
<br />•22a. GATEOF 144 RY.01A0'i'Day,
<br />22d. INJURY AT WORK?
<br />DYES
<br />NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ HomiEide
<br />`❑ Accident 0 Beit hill Ineeefigetton
<br />0 Suic de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACEOf INJ
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2N, OCAT(ON'OF INJURY; STREET &NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 22, 2022
<br />CITY/TOWN:;
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Jori f 29 2022 08;11 PM
<br />2,tdt TO i(1e,best ef7llv#cnowledgo death occurred at the time, date and place
<br />and due lathe causes) stated. (Signature and Title)
<br />Tvler4. Vette) MD �<
<br />21b, IF; TRANSPORTATION INJURY
<br />Orivar/Operator
<br />L Y Passenger
<br />❑ pedestrian
<br />Other(Specify)
<br />onaetto death
<br />19. WAS MEDIGAL;;EXAMINER ;!
<br />•
<br />OR CORONER:CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />RY-At home „farm, street, factory, office building, const
<br />Red
<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, On the basis of examination andfor investigation, in opinion death ocputred at
<br />thetinte date and place and due to the cause(s) stated. (Signature a1rdhie) ..
<br />25. DID TOBACCO US£ CONTRIBUTE TO THE DEATH?
<br />[ YES NO ❑PROBABLY ® UNKNOWN
<br />27. NAME<TIi'LEANDAOpRESS OF CERTIFIER (Type or Print
<br />Tyler J. Vette), MD, 2116 W Faidiey Ave Ste 400, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Ea NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO Q YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 5, 2022
<br />
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