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A
<br />ecaT�aart STATE OF NEBRtASK`tk r,r,r;rA,,,
<br />THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW Ti
<br />EE A 'RUE COPY OPINE 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 />DATE OP ISSUANCE
<br />..................................
<br />5/28/2024'
<br />LINCOLN, NEBRASKA
<br />20240314
<br />SARAH BOHNENKA
<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 />1..DECEDENT'S•NAME { Brat, Middle, Last, Suffix)
<br />Herr t;he1; Alen ;Sheffield
<br />4, Ci# rAND Sr'ATE @I7 TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Holdrece, Nebraska
<br />7 $QCIAL.SE!GURr .. t4UMBER
<br />605-72-8307
<br />86,...FACILITtNAME ({r not Institution, give street and number)
<br />Tabatha at Prairie Commons
<br />Sc. CITY OR.TOWN OF'DEATH {include Zip Code)
<br />Grarndl Island 48803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />sa.AGE Last Birthday
<br />(Yrs.)
<br />71
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa. PLACE OF DEATH:.
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9d: STREET AND NUMBER
<br />0903 Meadow WI y Trail'
<br />ot. MARITAL STATUS AT TIME OF DEATH 1E] Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />FATHER'NAM0 (Fiat,
<br />Herschel ° Sheffield
<br />iddle, Last, Suffix)
<br />10b. NAME OF SPOUSE (First Middle, Last, Suffix) If wife, give maidta
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OFDEATNIMo., ttayr107
<br />May 17, 2424
<br />. DATE OF BIRTH (Mo.,
<br />Dec+
<br />1952
<br />,7 •
<br />OTHER J Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />11g IN$TDE cm LIMITS
<br />YSS O NO
<br />Cindy Akerson
<br />it.eVER IN U $. ARMED FORCES? Give dates of serviceif Yes.
<br />(Yes, No, or Unk.) No
<br />ETHOD;OF DISPOSITION
<br />{j Buttal 0Don tion
<br />ticreirseitarti 0.0esareement
<br />[Q Removal' ❑ Other {Specify)
<br />14a. INFORMANT -NAME
<br />Cindy Sheffield
<br />ISa. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />18d. CEMETERY, CREMATORY OR Oi'HER LOCA'
<br />Grand Island City Cemetery
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />rdena Pfeiffer
<br />iON
<br />lie,.FUNERAI'HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island Nebraska •
<br />18b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEA' tl (Seeinstru(tioins•and examples)
<br />14b, RELATIONSHIPTO.DEOlitC4Nt
<br />Spouse
<br />18c. DATE (NO.,
<br />May 2 .2024'
<br />Yr,) . .
<br />ka;
<br />i3. PAR $ I. Enterthe sham of events- -disease, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory attest, 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 />a)cerebral infarction
<br />c.)0 it'.
<br />it rrra
<br />dlkaasa or cnrrif (e
<br />to iteettt)
<br />sequentially net rand
<br />any, lesdbtg to rite est
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />Ettkr ifs UNAEIti YINR t RU
<br />(dbaaaa or Injiitythat initiated
<br />resulting in dei
<br />h)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1t PARTft OTttER NGNIFICANT'CONDITIONS-Conditions contributing to the death but not resulting
<br />derilee ( vviitt 1ewy bodies, seizures, diabetes mellitus type 2
<br />20.#FF
<br />gMint, but pregnant within 42 days of death
<br />natrk but pregnant 43 days to 1 year before death
<br />pregntux witliln the past year
<br />22a..DATE OF;INJURY '(MA,
<br />RK?
<br />❑ YES ;_❑ NO
<br />22if(
<br />y, Yr.)
<br />21a. MANNER/3F DEATH
<br />® Natural ❑ Homiolde
<br />❑ Accident 0 madding Intteatigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OP:JNJU
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />UR'y STREET & NUMBER, APT.NO.
<br />23 , DATE OF DEATH (Mo., Day, Yr.)
<br />May 17, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />MaY 20,:>2024
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />11:14 AM
<br />ttl Tu the beet of my knowledge, death occurred at the time, date and place
<br />acid duets the:cause(a) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />DID.TOBACCO USE.CONTRIBUTE TO THE DEATH?
<br />❑ yES {} NO -Rip PROBABLY 0 UNKNOWN
<br />the:: underlying cause given in PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Ddiver/Operator
<br />❑ Passenger
<br />❑:Pedestrian
<br />0 Other (Specify)
<br />210. WAS AN JIUTOI
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLE'T CAUSE DEATH?
<br />0 :YES ❑ NQ
<br />Y -At home, farm, street, factory, office building, Co
<br />g
<br />2
<br />A.:
<br />STATE
<br />traction
<br />etc tf3�a
<br />DDB.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />toeOn the ti is of examination arnllor Investigation, in my opitdlm. dea ..4 acunad at
<br />dte tkns, date and place and due to the causes) stated, (SignatureanddTklei
<br />24b. TIME OF DEATH
<br />24d
<br />E PRONOUNCEO DEAD
<br />2 28a. HAS ORGAN OR TISSUE DONATION .BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27` OiAMkTITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />'Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68843'
<br />128a. REGISTRARS SIGNATURE
<br />28b. WAS CONSENT GRANTED?:
<br />Not Applicable If 28a Is NO EJ YES
<br />28b. DATE FILED BY REGISTRAR (M
<br />May 23, 2024
<br />Day, Yr.)
<br />
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