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, "„„, . , STATE OF NEBRASKA • .
<br />0400Avioffiosokz,v000•INA oop row.rwo,
<br />'4 do2_t...,:!442,4440kh!'„..':!'400,'L..,444$40RWt.:::'!°"1.11°'%1*!'onmonr.1;,!:!'vlAw°P!!;;Toiwacco-IT.:60.n!'1!!7h0Avai0.!7.!5#4 4., '''AiiiNg80YwgiiiiiigN"'!;
<br />THE RAISED SEAL OF STATE OF NEBRASKA, !....r.,pE•07-iftgs THE DOCUMENT BELOW TO
<br />(*me ORIGINAL RECORD ON FILE WITFCTRE Nggimsm. DEPARTMENT OF HEALTH AND
<br /><14UMAN.SERVICES;41TAL RECORDS OFFICE, WHICH IS THELEGALDEPOSITOR FOR VITAL RECORDS
<br />•
<br />DAT! OFS$UANE
<br />9/1 V2G2
<br />LINCOLN, NEBRASKA •
<br />202401528
<br />z▪ taa .r?
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT Op HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />. 22.12214
<br />•• Middle, Last, Suffix)
<br />. „ ,
<br />•:ThomesmEdwardm Fagan
<br />4 CFIYAND STATE Oft:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />i.,100*649vmr•AlopmfoR, •
<br />5�8-8 9280
<br />2. SEX
<br />Male
<br />ss,AGE Last
<br />(Yrs.)
<br />72
<br />513.:.UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DtkB9MP.,A
<br />Septeinbeiiiii.0202g.;
<br />6. DATE OF.BIRTM403., ba4Y4;j
<br />8b.EACI:L:ITY4IAME:(tnbt institution, give street and number) .
<br />CHI Health St: Francis
<br />;fic,•01*§H- tOWN.0:0:134a.TH (Include Zip Code)
<br />••••••
<br />1.2:Lire GrarldUland
<br />4.cf...#1.1vwriogr40.0.1.1ogRi.,„:
<br />ttlOrti,
<br />lis. FLESIDENCE,STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a,PLACE PF3EATh
<br />•::. HOSPITALsl
<br />,. ip:poem
<br />0 ER/Ou patient
<br />0 DOA
<br />Sc. CITY OR TOWN
<br />Cairo
<br />•
<br />October 44949,,
<br />OTHER 0 Nursing Home/LTC
<br />13 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />• .•
<br />OF DEATH Ei] Married 0 Never Marded
<br />tu 0 Married, but separated • CI Widowed 0 Divorced 0 Unknown
<br />6
<br />iddle, Last, Suffix)
<br />JEMES::Faati
<br />13 VER IN i4SslOgb,':ItCRCES? Give dates of service If Yes.
<br />8
<br />(Vas No, or OW No
<br />0 'IS. METHOD OP DISPOSITION
<br />attuq#!Qaonaon
<br />..
<br />iii
<br />Clikiihisvackti:dt4iiilsoacity)
<br />" - • .•
<br />33e. APT. NO,
<br />•
<br />• . .
<br />•
<br />s•storisioe„..41...
<br />ECP:•#E$....•••4: .
<br />Suffix) If wife, give trialrionninfa:>:.:1
<br />9f. ZIP CODE
<br />68824
<br />10b. NAME OF SPOUSE (first,
<br />Julie Kuszak
<br />Middle, Last,
<br />•<!,•: 7 12,mbrilgs844ANE. (First,
<br />ElleiOtk! .•!!!.Soeth
<br />14a. INFORMANT48Affiff1,'
<br />Julie Fagan
<br />113e. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />178. FLINERAI,HCMEffAiVIE AND MAILING ADDRESS (Street, City or Town„State)„ „,,
<br />Alt,OSIthiff0nerOt Horne, 2929 S. Locust Street Grand Island„NebtaSke
<br />18b. LICENSE NO.
<br />•
<br />Middle,
<br />CITY / TOWN
<br />Cairo
<br />CAUSE OF DEATH (See instruCtIons end examoles)
<br />gis. PART I. Enter dietitian Of events. tileelises, Injuries, or complications4hat directly caused the death. DO NOT enter tannins! events such as cardiac arrest,
<br />• respiratory wain, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />, • • . „
<br />4rilMccluk79pAiHrE (POO': s) respiratory failure
<br />eleeelre O4Ofl1tft1nn reeddin/011i •
<br />• d"":'1 DUE TO; OR AS A CONSEQUENCE OF:
<br />Sequentially ilet conditions, if B)pneumonia
<br />any ending to nip rano listui
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />afireflhatfffiffiftVIN3.4AuliC c)
<br />gi Hfral, idterlitaker Irgurlittrat
<br />the events teenninh in nee" DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST -
<br />:
<br />14b. RELATIOffiffiP TEEE4tifiEffi..:!
<br />SPOUSE
<br />September 7222
<br />•• • Fts!EPTSSkE •
<br />A0001
<br />•
<br />APPHEXNEATE IIVTERVA
<br />orisetIrschi*fri. •
<br />onset to.seath
<br />Days
<br />onset trr!fftrath
<br />• . •
<br />. •
<br />onsM to ciaattl. • • • • • •
<br />ICPARTfkOTHElft SIGNIFICANT CONDMONS.Condltions contributing to tria,darith but ncitffittlithiglitthirtirderlying cause given In PART
<br />• ,••, • \ • ••
<br />P. IFFE8rALE;
<br />- •
<br />.' ttiM11t
<br />...• •
<br />• year be'ef4toA
<br />butntro
<br />.Vritin • - iiin, in 42 days
<br />death
<br />22* DATE OFSOLJOY(MPDay; Yr.)
<br />21a. MANNER OF DEATH
<br />Coal not be determIn
<br />0 SidCide n ned
<br />El Nature
<br />d EIH9n*i
<br />0 Ac
<br />dent [1:441
<br />22b. TIME OF INJURY
<br />21.b.„1F TRANSPORTATION INJURY
<br />tiririVer/Operator
<br />4p#Oinger
<br />0.]PaCestrian
<br />o Other (Specify)
<br />1. 15•0fAa.tarbIOALSkAkINOg ii :••• • •
<br />OR 4PROtfC00NT-Aoncei • • •
<br />fj VES jN0• :. •• •
<br />21e. WAS AN AUTOPSY ogegoitii4OpT.
<br />.......
<br />. . ........ ...........
<br />El YES .NO
<br />21d. WERE AUTOPSY OftiNds:A*NitAISILE.
<br />TO COMPLETE CAUSE OF DEATH? 1.
<br />OYES
<br />22c PLActitItf itl'i(LIRY4At Ototpe, ltarrn..a.tteeL factory, office building, construction ZItra'affikSpac\Ity •
<br />, ••: . •
<br />22d. INJURY tiliiYottik'i 220. DESCRIBE HOW INJURY OCCURRED
<br />.4124 • OYES 0NQ
<br />....
<br />22f4viCATIotOr thquity,:: STREET & NUMBER, APT NO
<br />ba. DATE OF'DtATH (Mo., Day, Yr.)
<br />g-- September 1, 2022
<br />§ I 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />. :
<br />SeOiteinibilr6. 2022 05:56 PM
<br />4Timiiibegoroyiowieths, death occurred at the time, date and place
<br />::,1 l•
<br />*::.: endilualteltheindase(s) stated. (Signature and ntim
<br />S AnUd V. Stira, MD
<br />CL,
<br />:.:.
<br />CITY/TOM : STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ZtP00E
<br />24b. TIME OP DEATH • ..
<br />z
<br />•
<br />24c. PRONOUNCEb DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E if 140. paitue:,ttetais of examination and/or investigation, in my opinion tHatkaccariverraf::
<br />tatia,date and place and due to the cause(s) stated. diititnetureetitillite)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES E No: CI PROBABLY 0 UNKNOWN
<br />11. NAME, TITLE ARD ADDRESS tiPbewfiFtER (Type or Print
<br />AhubV. 80ra, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />12Sa. REGISTRARS SIGNATURE
<br />25a. HAS ORGAN OR TISSUE DOATIONBEEN CONSIDERED?
<br />0 YES :E,],]' • R),51,0,
<br />. .
<br />•
<br />• • , , .
<br />26b. WAS coNseNT. GRANT:etrriv Q•
<br />Not Applicable if 280 18140 y!$: CiD
<br />••
<br />28b. DATE FILED BY REGISTRAR DAY.:YF,-) • I:1 .
<br />September. 8,•2022
<br />
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