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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA tT CERTIFIES THE DOCUMENT BELOW TO
<br />$E A TRUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AI
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUAN E
<br />....... ..........................
<br />.:...12/612022.>
<br />LINCOLN, NEBRASKA
<br />202301884
<br />r
<br />Q.AI un
<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. DCS' pENTS*NAME (First, Middle, Last, Suffix)
<br />James William Cyboron
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Littleton, Colorado
<br />7.
<br />m
<br />m
<br />Sk1CIAL SECURITY NUMBER
<br />508-543330
<br />b. FACILITY -NAME (if notInnstitution, give street and numbfr)
<br />Select Specialty Hospital -Omaha (Central Campus)
<br />8c. CITY OR TO.,Y N OF. DE
<br />Omaha 5$124
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />TH (Include Zip Code)
<br />lid. STREET AND NUMSER:
<br />2303 North Englemen Road
<br />Sc. AGE - Last.BirthdaY'
<br />Vim)
<br />80
<br />Sb':UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSE PITAL. ;Inpatient
<br />+] ER/Ou patient
<br />❑ DOA.
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'&NAME (First, Middle, Last, Suffix)
<br />Adolph George Cyboron
<br />13. EVER IN U>S: ARMEDFORCES? Give dates of service if Yes.
<br />g (Yes, No, or Unk.) No
<br />d
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Don tion
<br />' ©>CrematiOty ❑ Entombment'
<br />fl Rtimbvel ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />18d. COUNTY OF DEATH
<br />Douglas
<br />HOURS
<br />MINS.
<br />22 16381
<br />3. DATE OF DEATH (Mo., Day Yr.'):
<br />October 19, 2022,
<br />8. DATE OF BIRTHiSto., Day Yr.)
<br />April 15, 1042
<br />OTHER 0 Nursing Horm
<br />0 Decedent's Hon
<br />0 Other (Specify)
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9 INS DE CrfYS#MITS `
<br />YES la NO .`
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sandra Nowicki
<br />112. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Rose Elvina Hansen
<br />14a. INFORMANT -NAME
<br />Sandra Cyboron
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranio
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATIi
<br />Grand Island City Cemetery
<br />Ta. FUNERAL HOME.NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alf Faiths Funeral.:'Home, 2929 S. Locust Street, Grand Island Nebraska
<br />16b. LICENSE NO.
<br />1071
<br />CITY I TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE
<br />October 25 2022
<br />raska
<br />CAUSE OF DEATH (See. it structlof s and examples)
<br />S. PART I. Enter the chain of events- -diseases, injuries, or complications4hat 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 />DIATE CAU88IF)nal a)Acute respiratory failure
<br />disease arFenditIon re6uttinp;
<br />in dosini
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EntetlhSONCt3RLYINGCAUSE' C)
<br />(disea*a:or injury that initiaiaU
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Bacterial pneumonia
<br />18.,PART IL O
<br />es
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ER SIGNIFICANT CONDITIONS -Conditions contributing to the death In
<br />APPRO7
<br />A
<br />INTERVAL
<br />not resulting in the underlying cause given In PART I.
<br />onset to death
<br />One Month
<br />onset to.;tteath
<br />onset to death
<br />19. WAS MEDICAL,
<br />OR CORONER OONTAC'f EO?
<br />❑ YES, IiSJ NO
<br />O. IF FEMALE: ,
<br />fl
<br />Not pregnant within past year
<br />.9 Fregnsnt al time of death
<br />❑ Not PP' gwa; but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />y4 223 :DATE OFINJURY(Mo Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES ONO,
<br />21a. MANNER OF H
<br />® Natural ❑ Homicide
<br />❑ Accident ❑Pending investigation
<br />O Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />pool/operator
<br />Paidenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES I NO
<br />21d. WERE AUTOPSY FINDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ,
<br />22c. PLACE OF INJURY -At home,; farm, street,' factory, office building, construction alto,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />, LOCATION QF IN.KIRYSTREET 8, NUMBER, APT.NC.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />October 19, 2022
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />02:08 AM
<br />Noveryiber30,2022
<br />3d. To the balder my knowledge, death occurred at the time, date and place
<br />and due td the;Ousels) stated. (Signature and Title)
<br />Darren J. Splonskowski, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />LJ Y5$ gy NO .❑;PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEA
<br />24d. TIME PRONOUNCED DEAD.;,
<br />24e, On the baste of examination and/or Investigation, in my opinion deatit oetnied at
<br />tits tbae, date and place and due to the eau e(s) stated. (Signature ardriBle) •
<br />•
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 121NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Darren J Splons#towski, MD, 1870 S 75th Street, Omaha, Nebraska, 68124
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />28a. REGISTRAR'S SIGNATURE •
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 30, 2022
<br />
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