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STATE OF NEBRASKA
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<br />WHEN THIS 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 />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />D11.7Eap ISSUANCE •
<br />.......... ....... .....
<br />itj'
<br />LINCOLN, NEBRASKA
<br />202402143
<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 />f .DECEDEN'1S NAME...tFiret, Middle, Last, Suffix)
<br />Iayton Eugene Milner
<br />4. !CIT1" si#ND S I'ATECE TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hibbing,.Minnesota
<br />7. SOCIAL SECURITY' NUMBER
<br />47436-4768
<br />AGE tast:Birthday
<br />(Yrs.)
<br />88..
<br />8b:' FACILITY'NAME (If not Institution, give street and number)
<br />CHI Health 5t. Francis HMS
<br />Eetl Y OR 7QWN Of DEATH (Include Zip Code)
<br />Grand lslend 58803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />Gd...REETAND NUMBER
<br />4080 W <:Capital A ienue
<br />9b. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a PLACE O.. DEATH
<br />HGSPITAL Ea Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />g Oa MARITAL; STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />g0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S' NAME (First, Middle, Last, Suffix)
<br />Robert Milner
<br />It EVER IN tit i ARMED FORCES? Give dates of service it Yea.
<br />? (Yes, No, or Unk.) No
<br />Y 16. METHOD OF DI$PQSITION
<br />Buxtai} Donation
<br />Cremation ❑Entp#nbment
<br />00 Removai' ❑.atter (Specify)
<br />I
<br />b:s
<br />is
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 06028
<br />3. DATE OF MATH (Mo et t, Yr.
<br />April 30, 2024
<br />6. DATE OF E1141TT(
<br />rr3aSh
<br />November 17,.1935.:>..:.
<br />OTHER 0 Nursing Horne/t1L"!'
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g INGIDE t:
<br />i Pas
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden Withi
<br />Barbara Galich
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />I
<br />Cecelia . '; Krause
<br />14a INFORMANT -NAME
<br />Barbara Milner
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />7a, FUNERAL HOME NAME AHD MA UNG ADDRESS (Street, City or Town, State)
<br />Uvin Istonl Sondermann Funeral Home, 601 N. Webb Road, Grand (slandNebraska.;,
<br />CAUSE OF DEATH (See instructions and examples)
<br />IS. PART I. Enter the chain of events- -diseases, injuries, or complicationsdhat 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 adamants lines H necessary.
<br />IMMEDIATE CAUSE:
<br />Mfb1EDIATE CA taE ifInat i:: a) lschemiC colitis
<br />wase cr contl,Hiom reealea
<br />Sequentially list conditions, H
<br />any, Wading to Me tibiae, smut
<br />Ether ti's UNti*weiNG CAUSE
<br />Idtreae'or ieljury ehn'iniNeted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Peripheral vascular disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />15,::PARTU. ;1THERSIGNIFICANT CONDITIONS -Conditions contributing to the::death biut hot rests ting In the underlying cause given In PART I.
<br />Chronic obstructive,pulmonary disease, Coronary artery disease
<br />0. IF FEMALE;
<br />E Nqt pra9naat wjt)n 00: Year
<br />Prognam alt throe of diet*
<br />Ntn.pregrtdt bat p$Gnent within 42 days of death
<br />❑ Not pregnant but pregnant 43 days to 1
<br />year before death
<br />Unknowntt pregnant within the peat year
<br />DATE OF INJUFh' (f0•: , Day, Yr.)
<br />g J22d. INJURY AT WORK?
<br />I D YES ❑ NO
<br />I.. LOCATIO I OF INJtt
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homrcide
<br />0 Accident ❑ Padding Investigation
<br />❑ •
<br />Suicide ❑ COutd not be daanniaid'
<br />22b. TIME OF INJURY
<br />22c. SA
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23* DATEOF DEATH (Mo., Day, Yr.)
<br />April 30, 2024
<br />21b IF TRANSPORTATION INJURY
<br />❑ Dover/Operator
<br />❑ P;assenger
<br />❑ Pedestrian
<br />❑ Other(Speeify)
<br />f LIMIT$
<br />C : NO:
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16C. DATE. (Alio., Day, Yr.),.
<br />May 2, 20;
<br />STATE
<br />Nebraska :.
<br />APPROXIMATE INTERVAL.
<br />onaet;to dell
<br />1
<br />V1/401(P'
<br />onset to death.
<br />Years
<br />15. wAs ritgOVAL, OpArnifigft
<br />OR CORO* CONTACTED? .;,,
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED.
<br />Q YES J NO
<br />21d. WERRAUTOPW .FINDINGS AVARABLS
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO;
<br />OF 1NJUTtV At hym6 farm„street, factory, office building, consent
<br />CITY/TSTATE
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 2 2024
<br />23d..7. She baht of My knowledge. death occurred at the time, date and place
<br />< and due tail* ''cause(s) stated. (Signature and Title)
<br />Travis'S. Hageman, MD
<br />23e. TIME OF DEATH
<br />12:00 NOON ,
<br />24e: DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED Peso
<br />:3403M the':.iasis of examination and/or investigation, in my epkWe
<br />the time, dale and place and due to the cause(s) added. N/gadWril
<br />26. DID,TOBACC0 USE CONTRIBUTE TO THE DEATH?
<br />�XI YES ; ❑ NO :;'❑ PROBABLY ❑ UNKNOWN
<br />27. NAME=, 'nTLL AI+(D AGGRESS OF CERTIFIER (Type or Print
<br />Travis S #ia etr an, MD, 729 North Custer Avenue, Grand Island, ebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ANO
<br />28a. REGISTRAR'S SIGNATURE
<br />44-11 8.0 ./.ink
<br />26b. WAS CONSENT GRAN'TED?..
<br />Not Applicable if sale NO ©rt
<br />CIO
<br />28b. DATE FILED BY REGISTRAR (Mo ,,Day Yr.)
<br />May. 3, 2024
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