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<br />STATE OF NEBRASKA
<br />fl.5t4rAN`r ar r°tR'hfPPifilTdiXa=> rr/5yigVtalaas a�Yr(U.BPffffOdSS.:,; alrrVVaaaar s �,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A,TRU E COPY 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 OF I$$tJANCE
<br />'1/2612023
<br />LINCOLN, NEBRASKA
<br />202301961
<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 />1.OECEDENTS-H1rst, Middle, Last, Suffix)
<br />Car yfl ;.dean G)Iroy
<br />ANDSTAT
<br />CERTIFICATE OF DEATH
<br />R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cedar Rapids, Nebraska
<br />7 -::SOCIAL S€CURITY"NUMBER
<br />506-54-5891
<br />b. FACILITY -NAME (if not Institut ion, give street and number)
<br />Tiffany Square Care Center
<br />8c CITY QR TOWN OF DEATH (Include Zip Code)
<br />Grafld Island 68803
<br />RESIDENCE -STATE
<br />braska
<br />9i1:..STREETAND NUMBER
<br />15 E 20th
<br />9b. COUNTY
<br />Hall
<br />Si. AGE - LastBirthday
<br />(Yrs.)
<br />79:. _.
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL. 0 inpatient
<br />❑ ER/Outpatient
<br />0 OQA
<br />ITAL.STATLISAT TIME OF DEATH ® Married 0 Never Married
<br />Married, butseparated ' ❑Widowed 0 Divorced ❑ Unknown
<br />1 >= NJ R SINAME {First,
<br />Alouis Kieflner, ;.
<br />Middle, Last, Suffix)
<br />g 13. EVER IN U:§ ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Oak:) No
<br />ETHOD OF DISPOSITION
<br />Burial [ Don tion
<br />Ii Cremation Q Entombment
<br />Q Rtdmovsl Dotner (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />Sc. UNDER'I DAY
<br />HOURS
<br />MINS.
<br />23.00851
<br />3. DATE OF DEATH .(Mo. Day Y;.:
<br />)
<br />January 2!) 2023
<br />L DATE OF BIRTH (Mo,, Daq,'W.),
<br />OTHER 0 Nursing Home/LTC
<br />❑; Decedeetr Nome
<br />❑ Other (Specie,)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />tab. NAMEOF SPOUSE'(Flrst, Middle, Last,
<br />David Gilroy
<br />9f. ZIP CODE
<br />68801
<br />Ica FACINty
<br />t9t1. M) Crl'?'LIMeTs
<br />Suffix) If wife, give maiden name
<br />112, MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Henrietta Boesch
<br />14a. INFORMANT•NAME
<br />Dave Gilroy
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />16a DATE Mo, Day Yr,
<br />January 23, 2023
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />::FUNERAL, HOMtNAME AND MALUNG ADDRESS (Street, City or Town,. State)
<br />utter #neral Chapel, 3005 S. Locust St., Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />68.
<br />15. 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 if. necessary.
<br />IMMEDIATE CAUSE:
<br />a) adult failure to thrive
<br />et
<br />m tfsaihf
<br />EDIATE CAF..
<br />dieeass dr colidMon titeti
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, It b)Cerbrovascular accident
<br />env, leading tothe cause !feted
<br />DUE;:
<br />Enter the UNDBRLYIN1; CA1f8E C)
<br />(disease or InI1Ny tl n ttatad
<br />the events resulting in death)
<br />IAST
<br />OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />t8 ;l?ARTiI OYHER SKNSFICANT CONDITIONS -Conditions contributing to the:death but not resulting in the underlying cause given In PART L
<br />vascular dementia
<br />)F FEMALE ;,
<br />�; Not pregnane wflMn paeL veer:
<br />0 Prbpttintattknsofdeath
<br />0,' Not pregedht, bat ptagnant within 42 'flayed death
<br />S. m ❑ Not pregnant but pregnant 43 days to 1 year before death
<br />O Unknown#yregnaMwOhin the past year.;
<br />22d.INJURY AT WORK?
<br />❑ YES „❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural Homicide
<br />❑;Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />2.1.00p TRANSPORTATION INJURY
<br />❑ skiver/Operator
<br />,::Q passenger:
<br />'CrPedestrian
<br />❑ Other (Specify)
<br />I. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?'
<br />❑ YES Ili NQ
<br />21d. WERE AUTOPSII)N6P108:AVALABLe
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES, CI NO
<br />22c. PLACE OFIN,IURY-At home farm, street, factory, office building, consthu
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY STREETA NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />,lanuary.23.2023
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />12:20 AM
<br />&LID the best of my knowledge, death occurred at the time, date and place
<br />and dee tolhecause(a) atated.(Signature and Title)
<br />Ryan'b Crouch, DO
<br />26 DID TOBACCO USE ..CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES '® NO `❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c.. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Ice, etc.:;
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD..
<br />w
<br />xM :Dn the.beam of examination and/or investigation,.In my opiniondeath oceurtsd at
<br />•:tire time, date and place and due to the causes) stoned. (Signature ant Till)::'
<br />0 YES 21;v0:;:::
<br />7 NAMEI AND ADl1}tESS OF CERTIFIER (Type or Print)
<br />Ryan D CroupM, DO, 800 N Alpha St, Grand Island, Nebraska, 68803................
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO ❑
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 25, 2023
<br />i
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