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_.._._..__.....___STATE OF NEBRASKA
<br />tgue��• :6•fGlllylllCVJlt�1v r?ryiMNp� ai�t;'GP'/�fM,iPttt� s;. ..: �rp,rydr,�V
<br />WHEN 'I; HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUIVIAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/12/2023
<br />LINCOLN, NEBRASKA
<br />20240063
<br />SBOHNENKAJV
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />..... ..........
<br />...... ........
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DECEDENT'$ -NAME. (First, Middle, Last, Suffix)
<br />Richard :Let#. dSinpson
<br />CERTIFICATE OF DEATH
<br />4 crivAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />740CW. SECURITY NUMBER
<br />505 36 3136
<br />6b. FAC LIl Y -NAME I. not Institution, give street end number)
<br />426 South Woodland Drive
<br />B CITY OR TCWN OF DEATH (Include Zip Code)
<br />Grant( Island 68801
<br />9a. RES)DENCE4TATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Ba. AGE Last Bi day,
<br />(Yrs.)
<br />92
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />(0 Pl ACE ORDEATH
<br />HOSPITAL ❑:Inpatient
<br />�y ❑ ER/Outpatient
<br />❑ DOA
<br />Sd. STREET AND NUMBER
<br />425 South Woodland Drive
<br />los. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.'FATHER'S.NAME (First, Middle, Last, Suffix)
<br />Harley Simpson
<br />13 ;'EVERlN US ARMED:FORCES? Give dates of service if Yea.
<br />(Yea, Na, orUnk.) Yes' 09/14/1951-06/19/1953
<br />16. METHOD OF DISPOSITION
<br />n—.
<br />❑ Donation
<br />al Crematio r i ❑ Entismbment
<br />:ORA/novel : ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />lab. NAME OF SPOUSE (Fir!
<br />Sonia Herrmann
<br />14a INFORMANT -NAME'
<br />Sonja Simpson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />HOURS
<br />MINS.
<br />3 DATE OF tTN'(Mct, Day, Yr'
<br />Deta mbar 1 202
<br />8.' DATE OF BIRTH.(Mo.;
<br />uiy 11, 1
<br />Yr
<br />OTHER 0 Nursing Hol
<br />® Decedent's
<br />0 Other (
<br />lad. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />if. ZIP CODE
<br />68801
<br />12. MOTHER'S -NAME (First, Middle, M
<br />Helen Lyle
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />lie. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Towi), State)
<br />All Faiths;Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska for
<br />Other (SDeclfvl
<br />CAUSE OF DEA'I`i (Seel Instructionsand examples)
<br />15. PART I. Enteral»chain Of event,- .dt,Wes, injury.., or compllcations4hat directly caulked' the death. DO NOT enter terminal events such ea cardiac arrest,
<br />respiratoryarmt, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional tines If necessary.\
<br />IMMEDIATE CAUSE:
<br />BrIMEDIATE CAUSE IPIne)
<br />Masao ter condition telultill
<br />$)Waldenstrom's Macroglobulinemla
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Sat conditions, Ir b)
<br />any, leading to she cause listed
<br />on tinea. ..-
<br />the ever
<br />LAST
<br />rose
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />A(iils c)
<br />Mated
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />I8 :PARTI# 01: ER 31GNIP)CA)
<br />anemia hypertension; stets
<br />20. IF MLE
<br />f ctpcsgnFEAlettMMin pat,i:Ya
<br />Pregeant atjdmt, of dsattf:
<br />Net pregnant but pregnant wititin t,4 days of death
<br />❑ Not pregnant but pregnant 4.1 days to o year before death
<br />"N°1,!, pregnant whin the pest year
<br />T CONDITIONS -Conditions contributing to the death but not resulting !;in the underlying cause given In PART I.
<br />fibrillation, heart failure
<br />A
<br />OF:INJURY (Mo.,. Day, Yr.)
<br />INJURY AIT WORK?
<br />OYES ONO
<br />21a. MANNER ryOF DEATH C
<br />Natural Honiictda
<br />❑ Accident ❑ Pending hsysstigatoh
<br />❑ Suicide ❑'Could not be determined.:
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />DrlwNOpenmor
<br />Pnaeenger
<br />❑ PSdestden
<br />❑ Other (Specify).
<br />21d. WIRE AUTOPSY IR
<br />NDINGS A1fA1LAl
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑
<br />YES
<br />[ NO
<br />22c. PLACE OF INJURY.Athonle,'thrn, street, factory, office building, conatru
<br />CRIBE HOW INJURY OCCURRED
<br />A11ON;;OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN:`
<br />"kL DATE OF>I3EATH (Mo. Day, Yr.)
<br />December 1, 2023
<br />23b. DATE SIGNED (Mo, Day, Yr.) ; 23c. TIME OF DEATH
<br />Deepenlber 4.2023 06:27 PM
<br />III To rite IMA of My knowledge, death occurred at the tkne, date and piece
<br />and OW *the Ouse(*) sided. (Signature and Title)
<br />Chad Vieth. MD
<br />E
<br />STATE
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ME(
<br />Sde..Qn the tesla of examination andlor Investigation, M my spin
<br />.;the time','date and place end due to the causes) stated. ($
<br />28.'DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Cf YE <0 NO ❑ PROBABLY is UNKNOWN ❑ YES NO
<br />N46%. i17t,E AND:,A.pp Ess OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faldley #40'0, Box 9802, Grand Island, Nebr`askal 68803 .
<br />28b. WAS CONS
<br />Not Applicable if
<br />NT'G
<br />NO.
<br />26b. DATE FILED BY
<br />December 6, 2023
<br />R (Mo, DRY* Yr.)
<br />
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