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<br />STATE OF NEBRASKA >
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<br />W .EN;THIS COPY CARRIES THE RAISED SEAL OF STATE OF /IIEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBTh4 S#(A .IEPARTMENT OF HEALTH AND
<br />HUMAN SERiBCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DArEoF ISSUANCE
<br />1131/ 024
<br />LINCOLN, NEBRASKA
<br />i7
<br />0
<br />20240062'6
<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 />1 DECEpENT$-NAME;(First, Mlgdie, Last, Suffix)
<br />CvflttTla Ann Wiley
<br />CERTIFICATE OF DEATH
<br />4. PITY AND SttATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH •
<br />Grand -Island, Nebraska
<br />7.;SOMAL Si»GURrTY t(lMBER'
<br />507 62-14096
<br />5a. AGE . Las Birthday
<br />(Yrs.)
<br />r
<br />Sr.
<br />8b::FAOIL1TYfiiA ME{if ndt Institution, give street and number)
<br />2620 Cottage St.
<br />Sc . CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grat'td Island 68803
<br />ei.REM ENCE.StATE
<br />Nebraska
<br />9d.;..STREET AND MUM.?EII
<br />2624 Cattacre St;
<br />Sb. COUNTY
<br />Hall
<br />60
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8s Pl ACE pili DEATH :;,
<br />HOITAL ❑ Inpatient
<br />D ER'Outpatient
<br />0 DOA
<br />11Iy MAR/TAL.STATUS AT TIME OF DEATH Married 0 Never Married
<br />0 Married, but separated D Widowed 0 Divorced 0 Unknown
<br />11. FATHER S:NAME (First,
<br />I}Vililam J: Ryan.',
<br />Middle, Last, Suffix)
<br />13 EVERIN;U B ARMED`FORCES? Give dates of service if Yes.
<br />(Yes, No, orUnk) No
<br />15, MEHOD OF DISPOSITION
<br />031€sdat ❑ Dtrltalion
<br />Q Cremaboic Q» Entothbment
<br />Rewmovsl: t. i Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS,
<br />3. DATE OF'OSI TH Cid+s x Dtq' Yt
<br />Jan Jant1ary 19 2024
<br />(I�tl►o., Day: fir*
<br />s. DA
<br />Olt B)RTH
<br />August :1.1.1'
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />8f. ZIP CODE
<br />68803
<br />tab. NAME OP SPOUSE (WM, Middle, Last, Suffix) If wife, give me
<br />Kevin Willey
<br />112, MOTHER'S -NAME (First, Middle, Maiden Sum
<br />Joyce R; Jacobsen
<br />14a. INFORMANT.NAME"
<br />Kevin Willey
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />tie. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />outran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />80#)i$IRE .,
<br />YESNo
<br />LIMITS
<br />14b. RELATIC
<br />Spouse
<br />16c. DATE(Mo.,
<br />January fl:I
<br />gP To DIE DENT,
<br />Yi
<br />CAUSE OF DEATH (S :.if lStruatiorts and examples)
<br />14. PART I. Enterthe Chain cif events, disease, Injuries, or complications -that directly ceu49d the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory sweet, 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 />ik7MED1ATE cilt3eE(f a) Ovarian cancer metastatic
<br />tdhease r:cardigan
<br />frtteatk3..'
<br />Sequentially Vat conditions,:if
<br />any, leading to the cause listed
<br />omits a
<br />Efitlli'the UNDERLYINQ CAU
<br />(disease or iNuryr that inhietea
<br />wilting M death
<br />the events re
<br />LAST
<br />IUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />15. PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resetting In the underlying cau
<br />20, IF FEMALE:
<br />Rot Pfa{ptiirit vdthinpetit...
<br />I,.,f! Pregnant ir#ime 01' death'
<br />Nat p agent, but IYtegnaM wi hin 42 days of death
<br />Not pregnant, trot pregnant 47 days to 1 year before death
<br />El Unknown if pregnant within the Peetyear
<br />LDATEOF INJURY(I6[t , Day, Yr.)
<br />i' INJURY AT WORK?
<br />❑'YES ONO
<br />fCATIONOFINJURY
<br />21a. MANNER OF DEATH
<br />® Natural © Homicide
<br />0 Accident 0 pending lrweatigatlon
<br />O Suicide ❑ Qouid not be tlefermined
<br />22b. TIME OF INJURY
<br />given in PART 1.
<br />21b. IF TRANSPORTATION INJURY
<br />Dfiver/Operator
<br />Pa►senger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />22c. PLACE OF INJURY.Athome
<br />Kg
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />rREET A NUMBER, APT.NO.
<br />23a.:DATE OF DEATH (Mo., Day, Yr.)
<br />January 19, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 20, 2024
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />07:10 AM
<br />Ad 'fglne has. of,}i yknowledge, death occurred at the time, date and place
<br />And due to tt:6suse(s) stat, (Signature and Thiel
<br />Ryan Ramaekers, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO
<br />t THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES I NO PROBABLY 0 UNKNOWN
<br />18. WAS MMOjeAL EXAMINER.:;
<br />OR CORONER CONTACTED?
<br />❑ YES I NO
<br />21c. WAS ANAUTOPS. YFEI
<br />© YES NO
<br />21d. WERE)AUTOPSY tis. fl
<br />TO COMPLETE CAUSE
<br />❑ YES t N4
<br />arm, Street, factory, office building, cons
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d, TIME
<br />Ste. Oil the ptais of examination and/or investigation, in wily opit
<br />:the time, date and place and due to the cause(s) stated. OS•
<br />fl
<br />0 YES NO
<br />27. NAME, TITLE ANC? A)RESS OF CERTIFIER (Type or Print
<br />Rya#1 Remaekkers MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />44-11 .464re
<br />17 74/4-
<br />DEATH
<br />D
<br />Dj
<br />28b. WAS CONSENT GRAN
<br />Not Applicable if 26a Is NO
<br />28b. DATE FILED BY REGISTRAI
<br />January 30, 2024
<br />
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