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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,11' CERTIICIES THE DOCUMENT BELOW TO
<br />BETRUE COPYOF THE ORIGINAL RECORD ON FILE WITH 7IIE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE„ WHICH IS THELEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />111 7/2023
<br />LINCOLN, NEBRASKA
<br />2024018
<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 />CERTIFICATE OF DEATH
<br />17DECEDENTS-NAME 4First, Middle, Last, Suffix)
<br />Faslane 3N)i)larti'<. Maines
<br />4: CITY AND $TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Elmira, New York
<br />7,SOC)AL S.ECURITYtIUMBER
<br />26341940:751
<br />8LAGE - t aet Birthday
<br />(Yrs.)
<br />63,
<br />fibsFACILITY.NAME:(tlnothtstlbdlon, give street and number)
<br />UNMC
<br />8c.:CITY OR i O N OF DEATH (include Zip Code)
<br />Dmeha 68198
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLA9E OF DEATH
<br />HQSPITAL 12 lnpaUent
<br />0 ERJOutpatlent
<br />❑DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo„ gay, Yr.)
<br />November 18; 2023
<br />8. DATE OFiBIRTH (Mo., Oak Yr.)'
<br />March 12 1
<br />OTHER 0 Nursing Horne/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />p(ce Facility
<br />94 STREET AND NUMBER
<br />2211 Woodridge.1.one
<br />fie. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9p INSIDECI7"IrLHN
<br />® YlaB CI.=NoO
<br />.''
<br />.......................
<br />too; MARITAI STATUS,AT TIME OF DEATH 0 Marded 0 Never Married
<br />0 Married, but separated 0 Widowed NI Divorced 0 Unknown
<br />14>FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Howard . Maines
<br />1Ob. NAME..OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden ria
<br />12 1NOTHEffiS-NAME (First, Middle, Maida
<br />Shirley Moses
<br />13; EVER IN U$. ARMED FORCES? Give dates of service if Yes.
<br />(Yee, No, or Unk.) No
<br />14a. INFORMANT NPME
<br />Michael Maines
<br />14b. R
<br />Son
<br />LATIONSHIP TO DECEDENT;'
<br />a
<br />15. METHOD OF DISPOSmON
<br />a,00000.
<br />Cremations Q Entombment
<br />0 Removal © Other (Specify)
<br />180. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.FUNERAL .HOME NAME AND MAIUNG ADDRESS (Street, City or Town. State)
<br />All Faiths Funeral Home 2929 S. Locust Street, Grand Island. Ne
<br />18b. LICENSE NO.
<br />CAUSE OF DEATH (See instruct)on;
<br />CITY l TOWN
<br />Gibbon
<br />nd examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT ardor terminal events such as cardiac arrest,
<br />respbatory 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 />ikWEDIATECAUSE (f$qu a) acute decompensation of chronic lKier disease;
<br />dinaaea or condkton resulttna
<br />Sequentially get condmans,.l1
<br />any, leading to the twee hated
<br />onhlne L
<br />Emla„ the UNDER MNG DAU8E
<br />(d(sei a or injury ehattiiitlated
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />i8t DATEtMo., Oa_.
<br />November 2G 202'
<br />Yr) ..
<br />AP
<br />STATE
<br />Nebraska
<br />onset to death
<br />Davis To:weeks ..
<br />18.:PART U OTHER SIGNIFICANT CONDITIONS-Conditlons contributing tothe deathbut not rasuY It
<br />lrrultifaetorial shook
<br />20. IF .FEMALE:,
<br />Q Not pregnant within paat:yaar
<br />0 ProyngrttatMtneotdesttt>
<br />❑ Not yregnsot, but (?regnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />O Unknown i :pregnant within ails past year
<br />21a. MANNER QF DEATH
<br />Natant ❑ Horm0da
<br />❑ Accidsm ❑ Ventlinp lnvaedgatidn
<br />0 Suicide El could not bs determined
<br />In the underlying cause given in PART1.
<br />21b:::IF TRANSPORTATION INJURY
<br />Dri !edOperator
<br />Q riaasenger
<br />Q:Pedestrian
<br />❑ Other lSpeciy)
<br />19. WAS M
<br />OR CORONEE
<br />L) YES
<br />21c. WAS AN AUTOPSY`PER. ORMED?
<br />........ ..
<br />❑ YES NO
<br />21d. WERE AUTOPSY f iNOINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22*. DATE OF': NJVRY (Moi, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES _QNO
<br />22b. TIME OF INJURY
<br />22c, PLA..
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.,LOCATION OF INJURY STREET 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 18, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 20, 2023
<br />OF INJURY -At hOfnti farm. street, factory,' office building, construction a
<br />CITYITOwN
<br />23c. TIME OF DEATH
<br />02:06 PM
<br />3d Tolhe best of my knowledge, death occurred at the time, date and place
<br />anddue titli ::tauae(s) stated. (Signature and Title)
<br />DerekA Kruse, MD
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />1 YES ] NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />246. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME
<br />29e: Gn tha:hais of examination and/or Investigation, in my of
<br />]:the tame', date and place and date to the cause(sf stated. (SI
<br />IP;COD
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES EZI NO
<br />27, NAMEb Ti tEAND ADDRESS OF CERTIFIER (Type or Print
<br />'Derek A Kruse, MD, 985990 Nebraska Medica Center, Omaha, Nebraska, 68198
<br />28a. REGISTRAR'S SIGNATURE ,.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 280 Is NO 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., D
<br />November 22, 2023
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