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<br />STATE OF NEBRASKA
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<br />WHEN nits COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO,
<br />BE A TRUE 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 ISSUANCE
<br />6/28/2023
<br />LINCOLN, NEBRASKA
<br />3
<br />X11 FAT'HERS,NAME (Picst, Middle, Last, Suffix)
<br />Thomas Leroy Davis
<br />��
<br />2023031677
<br />SARAH BOIINENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 DECEDENT .s HAMe,:lneet, Middle, Last, Suffix)
<br />Robe) t. ;Leroy.Davis
<br />CERTIFICATE OF DEATH
<br />4.0/TV AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />73OC(ALS.EDDI!TI NUMBER
<br />••50848-056i.
<br />8b. FAelLITY=NAME ((f not Institution, give street and number)
<br />•
<br />Grand Island Re17ional Medical Center
<br />Sc,OITY OR TOWN OP DEATH (Include ZipCode),
<br />Grand island 68803
<br />9a. RESIDENCE STATE
<br />Nebraska
<br />9d.STREETAND Numogg .,
<br />4227 Spriilpview Dr. .
<br />5e. AGE - Last: Birthday
<br />(Yrs.)
<br />81
<br />Sb- UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />9a. PI4CE OF DEATH
<br />HOSPITAL 0Inpatient
<br />10 ER/Outpatient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />19a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ DIvorced 0 Unknown
<br />1 S EVER IN 1144 ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.), No
<br />15,METHOD' C F DISPOSITION •
<br />.tilt Buttal ' ['Donation
<br />CretnatIon ❑ Enty tbment
<br />R emoval!' [ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF, DEATH
<br />Hall
<br />HOURS
<br />MINS.
<br />3 DATE csEIDEATKpifoOlak,
<br />June 18, 2023
<br />4.
<br />S. DATE OP; BIRTH'(Mo, Day, Yr.)
<br />December.170:941 ::,.. .....
<br />OTHER 0 Nursing Hoene/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />4g. INSIDE CITY UNITS
<br />Cf YesjNc1
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give madden flesh
<br />Adrianna Badura
<br />4:: 12.41. OTHER'S -NAME (First, Middle, Maiden Surname
<br />Bualrne MCcarty
<br />14a. INFORMANT -NAME
<br />Adrianna Davis
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />1Nestlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Fu feral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1092
<br />CITY/ TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DI3a31)EN' `
<br />Spouse
<br />lSc. DATE(Mo., Day, Yr.)
<br />June 24„3
<br />ATE
<br />Nebraska
<br />CAUSE OF DEATH (See :€nstructio a and examples)
<br />18 PART 1. Enter the chain of events- -diseases, injuries, or compliceeone4hat directly caused the death. DO NOT enter tennhwi events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />9h aEDIAIS CAUSE (Irina a) Sudden Cardiac death
<br />dtsfesedfrcondhlenresultlng
<br />In dam) DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially llatconditions, if b) cardiopulmonary arrest
<br />any, teadin9:to the cases listed
<br />DUE
<br />YhpOCAose C)
<br />(disease or to jwythat tngiated
<br />the events resulting
<br />LAST
<br />h)
<br />18':PARTII.
<br />htE
<br />IPI
<br />, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />,20.'IF FEMALE.,:
<br />❑:,Notpregna twiaatpest:year,..
<br />. Pregnantattimeardeath .
<br />1
<br />: idol p'e9naid, but pregnant within 42 days of death
<br />❑.. Not pregnant, but pregnant 43 days to 1 year before death
<br />�. Unknown ifSregFMnt vritiNn the treat Year
<br />APPROXIMATE INTERVAL
<br />onsetto death
<br />Immediate
<br />onset to death
<br />Immediate
<br />NT CONDITIONS -Conditions contributing to thedeath but not resulting
<br />a*.11(ATE O)rap
<br />(II
<br />22d. INJURY AT WORK?
<br />❑YES ::❑N0
<br />Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natured
<br />0 Honuside
<br />❑ Accident ❑ Pending mvudgation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />In ttte underlying cause given in PART I.
<br />21b. IF TRANSPORTATION
<br />0 Dthrer/Operetor
<br />❑ neatenoer
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />19. WAS MabieXL EE: NSA
<br />OR CORONER CONTRb?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES El NO .
<br />21d. WERE AUTOPSY'FI#IDINGS AvAILA I E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑'yEta CJ NO
<br />22c. PLACE OF INJURY -At home, tan(), street, factory, office building, construction sit, oc.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />24 .00ATION.OFINJUR'f . STREET& NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />June 18, 2023
<br />23b. DATESIGNED(Mo., Day, Yr.)
<br />.lune 2s. 2023
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />11:59 PM
<br />Id,'7A:*be hestetilly knowledge, death occurred at the time, dateand place •
<br />and duo t0 ttln tante(s) stated. (Signature and Title)
<br />Ryan D Crouch. DO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />'CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24e:0n the base of examination and/or investigation, in my opinion d010 ercur bd et
<br />tike alit, date end piece and due to the cause(s) stated, (eIgnatrire an411tle): ...
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONAf
<br />❑ YESNe PROBABLY ❑ UNKNOWN ❑ YES 'ENO
<br />27 NAME TiT AO ASS OF CERTIFIER (Ty Print
<br />pe or n
<br />Ryan Cl CDDRErouch, DO;•800 N Alpha St, Grand Island, Nebraska, 68803
<br />BEEN CONSIDERED?
<br />25b.' WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO Oyes
<br />Ni
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.),
<br />June 28, 2023
<br />
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