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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 FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OF ISSUANCE
<br />9/28/2023
<br />LINCOLN, NEBRASKA
<br />2 0 2 3 0 6 2 4 5 ASSISTANT NATIREGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DE'i.EDENT' *NAME (First, Middle, Last, Suffix)
<br />Jo Raymond Graff
<br />4. CrfYANb STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />La Mars, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />482 52 5'754
<br />5e. AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />8
<br />8b. FACILITY -NAME (HOW Institution, give street and number)
<br />CHI,Health. St.:Francis
<br />6c.'(4TY OR TOWN OF DEATH (Include Zip Code)
<br />brand islarie .53803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />d STREET AND NUMBER:::.
<br />4:16 N Cherokee Ln €
<br />9b. COUNTY
<br />Hall
<br />'MARfTAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />11. FAITHEMS-NAME (First, Middle, Last, Suffix)
<br />Joseph Graff
<br />I, EVER tN U.S. ARMED FORCES?i
<br />(Yes, No, or Unk.) NC
<br />15. METHOD OF DISPOSITION
<br />Q 661161 ❑ Donation
<br />J Crematlon; ❑ Entombment
<br />❑'Removal ` ❑ Other (Specifyy
<br />ve dates of service H Yes.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />80. PLACE OF DEATH
<br />HOSf+ITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MO., Day, Yr.}:::
<br />September 20,::2023
<br />6. DATE OF BIRTNIMo., 60, 46
<br />March 10, 1944
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />10b NAME OF SPOUSE (First, Middle,
<br />Sharon R Loraditch
<br />14a. INFORMANT -NAME
<br />Sharon R Graff
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island,, Nebraska
<br />dl
<br />to
<br />9f. ZIP CODE
<br />68803
<br />Last, Suffix) If wife, give maiden name
<br />9$, IN$IDE CI Y iMITS
<br />tgj YES ❑ No
<br />12. MOTHER'S -NAME (First,
<br />Dorothy Rickters
<br />16b. LICENSE NO.
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO 0 N
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />September 22 ;2023
<br />STATE
<br />Nebraska
<br />1711, Zap:;Gode
<br />CAUSE OF DEATH e= ( rU fid xam
<br />PART I. Enter the chitin 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 />tMMEOIAtt3 CAusE (Penal a) coronary artery disease
<br />disease or condlalpn resultlng
<br />in deathi DUE TO, OR ASA CONSEQUENCE OF:
<br />equentially est conditions, f b)
<br />any, leading to the cause listed
<br />on leas.
<br />DUE TO, OR As A CONSEQUENCE OF:
<br />EnteE the WNDERLYINO CAUSE C)
<br />tdreebse et' lniurr ttatlna(et60
<br />theavents resulting kt death) + DUE TO, DR AS A CONSEQUENCE OF:
<br />LAST d)
<br />APPROXIMATE INTERVAL
<br />onset to:death
<br />Years
<br />onset to death
<br />onset todeatt
<br />18. PART N, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to tho death but not osuitInlg in the underlying cause given In PART 1
<br />metastatic Nonsreall Sell lung cancer
<br />0. IF FEMALE:':.
<br />Not pregnant smith past year
<br />El Pregnant at One of death
<br />00 Mot pragnanti: but piegnam within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before: death
<br />❑ Unknown If Pregnant within the past year'
<br />DATE OF INJURY (Mo. Day, Yr.)
<br />22d. INJURY AT WORK? 0
<br />YES NO...._
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homlcide
<br />❑ Accident 0 Pending Imeetlgatfgtt
<br />0 Suicide ❑ could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />00VOloperator
<br />❑ Pas;anger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />19. WAS MEDtIA(-:ExAM NER.:
<br />OR CORONER CONTACTED?
<br />❑ Yes NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVA)EABLe
<br />TO COMPLETE CAUSE OF DEATH?
<br />▪ YES ❑ NO
<br />22c. PLACE OF INJURY.At home, farm, Street, factory, office building, construction site, tfte ($psd fy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f< LOCATION OF INJURY::' STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 20, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 22, 2023 03:20 AM
<br />211d. To the best of my knowledge, death occurred at the time, date and place
<br />and; due to the muftis) stated. (Signature and Tale)
<br />Travis S. Hageman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?'
<br />YESNO PROBABLY 0 UNKNOWN
<br />27. NAME, nTLEAND ADD*ESS OF CERTIFIER (Type or Print
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. 00 the Iasis of examination and/or Investigation, In my opinion death p rod at
<br />the date, date and place and due to the cause(s) stated (Signature an41.18e)
<br />•
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO .
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED? ,
<br />Not Applicable H 26a Is NO ❑ YES Q NO
<br />28a. REGISTRAR'S SIGNATURE -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 25, 2023
<br />0)
<br />CO
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