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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 />BEA TRUE COPY OF TWE 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 OP ISSUANCE
<br />5/8/023
<br />LINCOLN, NEBRASKA
<br />202302
<br />En 2
<br />1/4362.441/
<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. DECEDENT$' NAME (First, Middle, Last, Suffix)
<br />George . A Vtach
<br />4. CITY AND STATE (*.TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cotesfield, Nebraska
<br />i SOCIAL SECURITY NUMBER
<br />508-52.1360
<br />WAGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILI1 Y-NAME'(if: not Institution, give street and number)
<br />Bryan Medical Center West
<br />Sc. CITYQR TOWN QF DEATH (Include Zip Code)
<br />Llnco#n 68002
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />STREETAND NUMBER:'
<br />23 Linden'Ave
<br />9b. COUNTY
<br />Hall
<br />10a. MANiTAL STATUS AT TIME OF DEATH ®Married 0 Never
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unk
<br />�+ 11 FATHER'S -NANO (First Middle,
<br />George R Vlach >Jr
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes,
<br />3 (Yes, No, or Unk.) No
<br />Last,
<br />Suffix)
<br />v
<br />E
<br />C
<br />15. METHOD OF DISPOSITION
<br />la ❑Donation
<br />(.4;041660 t❑Entombment
<br />❑Removal Cotita (Specify)
<br />81
<br />Sb.IIJNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea PLACE OF DEATH ..
<br />HOSPITAL ® inpatient
<br />0 ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 06103
<br />3. DATE OF DEATH (Mtn., Day 'Yt),
<br />May 3, 2023.
<br />6. DATE OF BIRTI3 (Ino„ Day, Yr)
<br />February .1.{1942
<br />OTHER 0 Nursing HomefLTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />Married 1Ob NAME OF .SPOUSE (First, Middle, Last,
<br />Hewn Connie Jo Wheeler -Hansen
<br />12. MOTHER'S -NAME (First, Middle,
<br />Mildred ii/lcDonald
<br />14a. INFORMANTNAME
<br />Connie Jo Vlach
<br />3 i(Osppca Fa ll
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, give maiden
<br />16a. EMBALMER -SIGNATURE
<br />L. Todd Biester
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State),:.
<br />Atsfet Fune al Home, 1.1231k 2nd, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1152
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT '
<br />Spouse
<br />18c. DATE (Mo., Day, Yr.)
<br />May 8, 2023
<br />CAUSE OF DEATH (See Insltrugtiofie and examples)
<br />13. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT edger terminal events such as cardiac arrest,
<br />respiratory arrest, or ventrlcularfibrigetion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory failure
<br />IMN.EDIA'r81 CAUSE 1Flnat
<br />diepace or condhloe re401Ehn9
<br />in ddMl)
<br />Sequentially list conditions, If
<br />any, leadIng to the, cause listed
<br />Enteathe UNDERLYING CAUSE
<br />..
<br />(alseaee:ar iroury that fmBefae
<br />the events resulting In death)
<br />LAST
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />b) Bilateral Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Lung Adenocarcinoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 WART I9 OTHER SIGNIIICANT CONDITIONS -Conditions contributing to the death but no
<br />Maligi 11t 061108rdla(Effuslon ..
<br />20. IF FEMALE:
<br />Not pregnant within past year
<br />f+ daetati lwofdeath:.:
<br />t!idt plegnad:
<br />
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