|
114
<br />visitt
<br />h"may$iVemaifts
<br />�1
<br />0"ttil;tldlrsolo ((fl(,lllt itE(d6$ItimAttyt ?9/tnrokom 3 ikw so O to oititISF,ffirERt ok,„Jag
<br />STATE OF NEBRASKA T
<br />��9549GYYAVtt.�dr.;,<.�..,rArrr44rdne, t ci46rGl
<br />hYlll(slll.44rd�Mdddcaa a4Ytt09yyli%1'ttDdd�t � uYlMiWfAfJ.r�
<br />131,II.1
<br />Ogee
<br />j`l1t ruliem,atl
<br />iilii,fV :tS(G4ae
<br />WHEN IMLs COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT;CERTIPIES THE DOCUMENT BELOW TO.
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMANSERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEOF1S UANCE
<br />9/21 /2023
<br />• LINCOLN, :NEBRASKA
<br />202305854
<br />80/1.4,41
<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 />t DECEDENT`S-NAME (First,.. Middle, Last, Suffix)
<br />•Gary Dean Sears
<br />CERTIFICATE OF DEATH
<br />4. CITY AND 8T'ATE OR::TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Stockton, ,California
<br />7 sociAL SE URITY NUMBER
<br />50.7-62 2437
<br />eb 'FACILITYNAME (IfnotInstitution, give street and number)
<br />704 N. Custer Ave
<br />Bo;.OITY OR TOWN OF DEATH (Include•Zip Code)
<br />Grand Island 88803
<br />9a.'itESiDENCESTATE'
<br />Nebraska
<br />9d STREET AICD NUMaER
<br />7'04 N. CU:stet Aire';
<br />9b. COUNTY
<br />Hall•
<br />**OE -LastsBlrthda}r'
<br />(Yrs.)
<br />5b;:UND'ER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a .PLACE Dur oa4.17
<br />ilOSPJTAL []:inpatient
<br />"❑ ER/Ou patient
<br />0 DOA
<br />10a4IARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />Married; but'seperated' 0 Widowed ; 0 Divorced 0 Unknown
<br />11.; logo S*NAMis' (Fkst, ' ; IlMlddle; : Last, Suffix)
<br />John Beaufofd Sears •
<br />13 SEVER IN U 9 ARMEDFO
<br />(Yes No, or Unk) N0, •
<br />1'5..
<br />ETHOD,OF DISPOSITION:
<br />Ekitial Q Donation
<br />cremation Cj Entombment
<br />Removal ❑Other (Specify►
<br />•
<br />ES?.Give dates of service if Yes.
<br />•
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH;(Mo pay YA)
<br />Septembel•..2,: 2023 ..•
<br />.....
<br />6. DATET :OF BIRTH (Mo., Dey; qtr:)
<br />December:23,:1947 ;;:
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />]777Te. APT. NO:
<br />9f. ZIP CODE
<br />68803
<br />de Fae llty
<br />0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n
<br />Connie Embrey
<br />14a. INFORMANT -NAME
<br />Connie Sears
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12, MOTHER`S-NAME (First, Middle, Maiden Sunlitn
<br />Christine Papline Hauf
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a..FUNERAL;0OMENAME AND MAILING ADDRESS (Street, City or Town, State)
<br />A(I Falths`uneralHome, 2929 S. Locust Street, Grand Island Nebraska
<br />CAUSE OF DEATH (Sen
<br />fstruc
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />rise and examples)
<br />18.;PART 1. EMS!' the chain 'of events, injuries, injuries, or compiicetionsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />'. trsepiretory arrasp:or ventricular fibrhlationwithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />EIMATSCAusE (Rtat ;5 ; 0):Netural.Causes
<br />disease orGen4eian restri)ifi:
<br />14b. RELATIONSHIP TQ DECEDENT`
<br />Spouse:
<br />16c. DATE (Mo Day,Yr.).
<br />September 6 .203
<br />in
<br />=DUE rd, 'OR.AS A CONSEQUENCE OF:
<br />gpentiallyaist.bond'mons; ,M,;...: b) Unknown
<br />aili,1e58$ ng to4h1' cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Fuse) thhUNDiF$.%'INGt)AU9E C)
<br />�;(dieeksa or ytjueythat int{ifited
<br />:aiie_e_ tints resuking iri death/ DU E TO, OR A CONSEQUENCE OF:
<br />•11•
<br />NwtCANT CONDITIONS -Conditions contributing to the death but n
<br />20
<br />EMALEi.
<br />pregnant whhtn past year
<br />regnant.gto i;ordeaitx,
<br />regnant; otdoognant elthio 42 days of death
<br />Nat pregnainf, but pregnant 43 days to 1 year before death
<br />Unknown if:pi gnaht.w,ithin theibl$t year ;
<br />22a.DATE OF'1NJURY 1Mp .Day Yr.)' .
<br />22d. INJURY ATWORK? `
<br />❑YES
<br />21a. MANNER OF DEATH
<br />® Natural Q Homicide
<br />0 Accident Q Pandang InYeStigi tfbn
<br />El suicide ❑ Could not be determined
<br />;STATE
<br />•
<br />•:
<br />
|