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STATE OF NEBRASKA
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<br />1444Ektla:CoPiCABRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EE A 'TRUE COPY OF.THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />'HUMAN SERVICES;'VITAL RECORDS OFFICE, WHICH IS THE DEPOSITORY FOR VITAL RECORDS
<br />riktg r l$.$1I4NCE
<br />LINCOLN, NEBRASKA
<br />^/•.I�J (� JSAH BHNENKAMP
<br />M
<br />2 0 4 0 3 0 9 0 ASS STANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 f7Et,EDENTS NAMfe (Ffirst, Middle, Last, Suffix)
<br />r01f : Michael : Mayoralty
<br />t CITSANQ tTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Crete; Nebraska..
<br />'I:.3OC(Al.. SEECURITFNUMBER
<br />508 T6.6.647 ...
<br />ba. AGE - Last Birthday
<br />(Yrs.)
<br />8ti FACILITY;MAME`(if not Institution, give street and number)
<br />1.610 Meadow...Road
<br />8c. CITY OR TOWN OF DEATH (IMcRde Zip Code)
<br />rand island;; 88803
<br />9a, RESIDENCE STATE
<br />Nebraska.
<br />e f <smET AND I UNBEft
<br />1.610 leadow Road
<br />9b. COUNTY
<br />Hall
<br />56:
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />be. UNDER 1 DAY
<br />3. DATE OF CRAM:(f a: Etay Yr
<br />Mey 0, 2024
<br />8. DATE OF BIRTH (fdo. Day, Yr.
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />1Das>MARtTAI STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1t,FATH0S 4AME:: (Pkat,
<br />I on$d Jaltforakv
<br />Middle, Last, Suffix)
<br />13AVER IN tl.8. ARMED FORCES? Give dates of service if Yes.
<br />(Yes; No, or link.) NO:
<br />15 )ETHbD;OF DlSPOSITtoe
<br />C Buttal Donation
<br />Cremstlo* fl Ento ltbment
<br />Remo4ai" (t)Eher (Specify)
<br />9c. CITY OR TOWN
<br />..Grand Island
<br />HOURS
<br />MINS.
<br />Septemb 1:6..198 .
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent'oHome
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Angela Gutzmann
<br />14a. INFORMANT -NAME
<br />Angela Javorsky
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1Ttt ::F#NERAI«:NOME NAMEM AND MA LING ADDRESS (Street, City or Town, State)
<br />At1 F6aithiiiirl neral Home, 2929 S. Locust Street, Grand Island; Nebraska
<br />tI ECfr1FtiMITS
<br />12. MOTHERS -NAME (First, Middle, Maiden Sum
<br />Candi Gill
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See. tiStrttdtions and examples)
<br />1a'. PART I: Enter the engin efeyents--dideeses, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respkstory street, of veotricularfbratation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />(final a) neuroendocrine tumor of small bowel
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />aequaMiiuly hit conditions, If
<br />u)Y ,t1i.n i tcthe il.M,.,/4/ted
<br />+lnlihes DUE TO, OR AS A CONSEQUENCE OF:
<br />�(irn[,ehs t EJ LYIN (itAUSE C)
<br />(dia$a'N or ii /uiy thatin.Mated
<br />the vents resulting In death) DUE TO
<br />LAST , d)'
<br />, OR AS A CONSEQUENCE OF:
<br />14b. RLLATU MSH TOOESEDENT
<br />Spouse
<br />18c. DATE:;(Mo.,
<br />June 3:.:21 "
<br />"I8. PARi`li 0 MERSidOtheANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Cenaf falkirik ctn.hosls, hypertension, atrial fibrillation,
<br />til MALE.,
<br />prapbant vpiattn peat yew
<br />naatet:timexNdataA' .. .
<br />..pram Iwlarianast within 42 bays of death
<br />Q Not pregnan, but pregnant 45 days to 1 year before death
<br />❑:, 4*.ft,0,1 tf:pretjriatlwiltlin the Peet year
<br />;DATE Op1IJURY(M ti., Day, Yr.)
<br />22d, INJURY AT WORK?
<br />21a. MANNER OF DEATH
<br />Ea Natural 0 Honticida
<br />❑ Accident ❑ Pet dingimestigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />ciPassenger
<br />Pedestrian
<br />0 Other(Specify)
<br />19: WAS MEDICAL EXAisINER, :.
<br />60 CORONER Q4N1- Dh '
<br />O YEE
<br />21c. WAS AN.AUTOPSY PERFC RMR.0
<br />❑ YES ( Alii
<br />21d.AWEREAtITOPEY"PUitiINOtili (AJLAIR E
<br />TO COMP(.ETE CAUSE OF DEATH
<br />❑YEti.::
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, c
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />tION?OSiti.4 Y • STREETS NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 30, 2024
<br />23b GATE SiGNEtt(MO.,Day, Yr.)
<br />May 31 2024
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />01:19 PM
<br />rstmoy:knbwkidga, death occurred at the time, date and place
<br />Eri fhfi aausep) stetd. (Signature and Title)
<br />Chad Vieth. MD
<br />2if :Lit# TO(FACCO US€ CONTRIBUTE TO THE DEATH?
<br />YES :❑ NO .`. PROBABLY ® UNKNOWN
<br />a13NAtee;if'f tx AtiB AID. ESS OF CERTIFIER (Type or Print
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />trualinx
<br />21PCOt
<br />24a.: Dn the':basis of examination and/or investigation, in my epMDon tin*EtM
<br />the tirtie, date and place and due to the cause(e) statbd. (sINratuie :
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES MI NO
<br />GitBS# V th 1VFi , 21161N fiaidley #400, Box 9802, Grand lsland, Nebraska, 68803
<br />285. REGtSTR11R SIGAtATttRE t /� ,s
<br />28b. WAS CON
<br />Not Applicable if
<br />28b. DATE FILED:BYI
<br />June 5, 2024 :'
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