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<br />WHEN MIS 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 FILEWITH THE NI'I?BRASIq tEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI7.ORY FOR VITAL RECORDS
<br />DATE r F ISSUAl ICE
<br />5/25/202
<br />LINCOLN. NEBRASKA
<br />202304365
<br />S.
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />reiromo. 1 DECEDENT?$.NAME (Fkse,, Middle, Last, Suffix)
<br />Wayne t !rllmar Sass
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />2. SEX
<br />Male
<br />8a,•AtIE • Last Eit
<br />(Yrs.)
<br />?.S+I UIL"9L IRITYNUMBER
<br />605. 4-7912
<br />1
<br />8b.P'ACILITY41AME (t not MstiAdlon, give street and number)
<br />1911 W. 11th Street
<br />8c CITY OR TOWN' OF r7EATH (Maude Zip Code)
<br />Grant lalend 68803
<br />ea. RESIDENCE -WAY
<br />Nebraska
<br />9d STREET ANIS NUMBER
<br />1911 1'1 th Street
<br />5b UNDER 1 YEAR 50. UNDER 1 DAY
<br />MOS.
<br />90 :.
<br />8aa:PLACE Oi iDEATH.
<br />H ITTAL J lnptlttent
<br />© ERioutpatient
<br />I] DOA
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />10a WAIT AE STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑Widowed 0 Divorced ❑Unknown
<br />11. FATHERS:NAME t.
<br />Georl:te Sass
<br />Middle, Last, Suffix)
<br />13. evert N U S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes No, or Unk.) Yes 01/05/1953-12/19/1956
<br />15. METHOD OP DISPOSITION 16a. EMBALM •SIGNATURE
<br />BulftllDctnalon Katie M. Smythe
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />2306781
<br />3. DATE OF beknliwio.,
<br />May 12. Q
<br />DATE OP S4RTH
<br />OTHER 0 Nursing Herne/LTC
<br />Deatidentostffinsts
<br />❑ other(
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />®s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />104. NAME OF SPOUSE {{first, Middle, Last, Suffix) If wife, give maiden
<br />Doris Jessen
<br />12 MOTHLR`ENAME (First, Middle, Maiden Surname)
<br />Caroline =Dibbern
<br />14a.INFORMANT-NAME
<br />0 Crsmatlon EatolllbmeM
<br />❑ Removal, : ❑ Other {Specify)
<br />Doris Sass
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Wostlawn Memorial Park Cemetery
<br />17a. FUNERALHCME NAME AND MAILING ADDRESS (Street, City or Tovnl,.State)
<br />t Fa#hs Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />lab. LICENSE NO.
<br />CITY / TOWN
<br />Grand Isla
<br />CAUSE OF DEATH (Sea instructions) anti examples)
<br />18. PAREL. Enter the chain of events- -diseases, injuria, or complicatknuihat directly aussd the death. D0 NOT enter tannins! scents such as cardiac axe,
<br />respiratory array Or vantlteular fibrillation without showing the etiology. DO NOT ABBREVIATE. alar only one cause on a Inn. Add addINaat lass if e.wYiry.
<br />IMMEDIATE CAUSE:
<br />IMMEDIAlEaaaaa1Flaal a) dementia
<br />dki*:Aas or aemdttion rauitin4
<br />In death)
<br />14b. RELATtOAI
<br />Spout
<br />180. DATEPtoa
<br />IV 1
<br />17.•
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />aequerddaay lett comdnlwr+e, l b)
<br />any, Isadina to mace -.
<br />b
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(dkuwiili erinjuistEiremiiRG d
<br />the wants resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />10.:PART 11 Ol:nend GNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />Coronary artery dis•
<br />ease
<br />20. IF FEMALE
<br />pLq10.aea:i»9'nsac
<br />14).!.00040.44a:
<br />lad.progrsfli, ut pregnant wMlin 42 days of death
<br />❑ Not preenan4
<br />dbutbpregnam 4s Gaya 10 1 year before death
<br />n Unknown r.pteOnant wltltin the Pat Year
<br />320.0ATE rP IP44URV MO {Day. Yr.)
<br />22d. INJURY AT WORK?'
<br />❑ YES 0 NO„
<br />22f. LOCATION
<br />21a. MANNER OF DEATH
<br />® Natural Q Homicide
<br />❑ Accident 0 Pending Investiga3Tott
<br />0 suicide ❑ Could not be eetemtined
<br />ed
<br />the underlying cause given In PART1..
<br />22b. TIME OF INJURY
<br />22c. PLACEOF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21b. IF; TRANSPORTATION
<br />Oilvet/Operstor
<br />Pasoenger
<br />❑:PUMstrian
<br />❑ Other (Specify)
<br />JURY 21c. WAS
<br />21d.
<br />TO COMEPLiiTI
<br />aYE9
<br />rrxie, farm, street, factory, otlae;bulding, constrtetton
<br />ER, APT.NO. CITY/TOWN
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />1
<br />a MaY 12 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />a i May 15 2023
<br />23c. TIME OF DEATH
<br />09:40 PM
<br />Ipd Td iflo baK nry.#ino vie e doth
<br />sttated (signature end Mel
<br />occurred at the time. dare and place
<br />arlQ dee to the ceuse(s)
<br />Travis S. Hageman,
<br />28 DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />j Yts"S <� HO
<br />O. PROBABLY ❑ UNKNOWN
<br />24a. DA
<br />SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />DEA'
<br />24d. T15IMO
<br />24n. On th. Wa )e of exeminason andler borestIgagon, in sty apIrdentleaiiir
<br />the 1ktNg Aute and place and due to the cause(*) eaten (signature endues)
<br />28a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />• NAME,11TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />T1avis S . Hagerllel , MD, 729 North Custer Avenue, Grand Island, Nebraska, B+
<br />28a. REGISTRAR'S SIGNATURE
<br />844411.-4.07 okoPm ft-
<br />N
<br />CONSENT GRANTED?
<br />If28akNO
<br />28b. DATE FILED BY REGISTRAR (Me.,
<br />May 19, 2023
<br />
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