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<br />WHEN THIS 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 />PATE.OFISSUANCE
<br />........ .............................
<br />..................................
<br />6/20/2023
<br />LINCOLN, NEBRASKA
<br />aha 1: PECEDENT'SNAME (Pkat, Middle, Last, Suffix)
<br />Maureen Kay Brash
<br />202304858.
<br />SARAN BOIINENKAMP
<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 />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-$8*9705
<br />8b. FACILITY -NAME ()f not institution,; give street and number)
<br />1208 West 8th Street
<br />• 8c. ow ON TOWN OF DEATH (Include Zip Code)
<br />Gland aslattd 6880:1
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5a, AGE . Last Birthday
<br />(Yrs.)
<br />74:.
<br />Sb. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ERIOu patient
<br />0 DOA
<br />9d. STREET ANS NUMBER:
<br />1208 Weaat:Bth Street
<br />10a. MARITAL STATUS ATTIME OF DEATH ® Married 0 Never Married
<br />...❑ Married, but separated ❑ Widowed 0 Divorced, ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Gerald Patrick Melaughlin
<br />13. EVER IN US ARMED..FORCES? Give dates of service if Yes.
<br />(Yes, No, or link) No
<br />V• 15. METHOD OF DISPOSITION
<br />(;Burial•
<br />❑Donation
<br />Q Crematott ❑ Entombment
<br />❑ (removal ❑ Other (Specify)
<br />d
<br />8
<br />6
<br />14a. INFORMANT -NAME
<br />Brad Brush
<br />'16a. EMBALMER -SIGNATURE
<br />Timeree L Andreasen
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />23 08074
<br />3. DATE OF DEATH (Nto., Day Yr),.
<br />June 3, 2023
<br />6. DATE OF BIRTH Day, Yr,)
<br />July 12, 1948
<br />OTHER 0 Nursing Hot LTC ❑.►
<br />Decedent's Nome
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />12. MOTHER'S -NAME (First,
<br />Viola Kamler
<br />a Fsg1Sty
<br />18b. LICENSE NO.
<br />1390
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />9f. ZIP CODE
<br />68801
<br />Middle, Maiden Surname)
<br />CITY I TOWN
<br />Grand Island
<br />9p INSIDE CITY LIMITS
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16e, DATE(Mc.,
<br />June 9, 2623
<br />CAUSE OF DEA1 H<(See:instruDtlons and examples)
<br />1e. 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 />tMMEItlATIICAUSE( Pinel a) Chronic Obstructive Pulmonary Disease
<br />diaet $e or ecedid n reeeleng
<br />'Id In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />edretl any,;leedinp to the caws Hated
<br />i9 DUE TO; OR AS A CONSEQUENCE OF:
<br />EnterthsUNDERLYINQOAUSSC) unknown
<br />'3 (disease or Inluryttat Initbltita
<br />E20. IF. FEMALE:
<br />D Not pregnant within pastyeer
<br />pregnrM at tiros df death
<br />❑ Not pregnant; but pYegaant within 42 days of death
<br />io❑ Not pregnant, but pregnant 43 days to t
<br />year before death
<br />g Q Unknown Ifpregnsmwlt In the past year
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />17b. ZIp Code
<br />68803;.
<br />APPROXIMATE/INTERVAL
<br />onset 10 death
<br />10 Years.
<br />Ian
<br />18 PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />Chronic respiratory Failure with hypoxia
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicrde
<br />❑ Accident ❑ Pending Inyeetlgetkur
<br />0 Suicide 0 Could not be determined
<br />citing in the underlying cause given In PART L
<br />22a. DATECF INJ#JRY(Mo Day, Yr.)
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />ii ❑YES❑NO..:
<br />22f 1 OCABONliF INJUR'r STREET a NUMBER, APT. NO.
<br />I
<br />.od
<br />22b. TIME OF INJURY
<br />23a. DATE OP -DEATH (Mo., bay, Yr.)
<br />June 3, 2023
<br />21b.IF TRANSPORTATION INJURY
<br />l termeoperator
<br />tp:pesseneer
<br />❑ !Pedestrian
<br />0 Other (Specify)
<br />19. WAS' MEDICAL EXAMINER
<br />OR CORONERXIONTACTED?
<br />® YES ❑ No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES RI NO
<br />21d. WERE AUTOPSY FINDINGS AVAIIABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />13 YES 0 N
<br />22c. PLACE DF INJURY: At home, fart, street, factory, office building, construction site, tl1*. (Spee(
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 16, 2023 12:38 AM
<br />23d To the hest of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Michelle D Schiel, APRN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES III, NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2413.1'1M!
<br />OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. on the basis of examination and/or investigation, In my opinion death C4061d et
<br />the tlma date and: place and due to the cau e(s) stated. (Signature aad Tile) !
<br />I28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES j NO
<br />27. NAME, 7ITLE:AND ADDRESS OF CERTIFIER (Type or Print
<br />Michelle D'Schiel, APRN, 1201 Allen Dr Ste 163, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />[ ieC: Aar?. " ry r. er.�
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO Q YES lit NO:.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 16, 2023
<br />
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