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STATE OF NEBRASK
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<br />WH' EN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKAx IT CERTIFIES THE DOCUMENT BELOW TO
<br />BElt RUE COPY O( tHE ORIGINAL RECORD ON FILE WITH THE NEBRASi 4' DEPARTMENT OF HEALTH AND
<br />. 1'IrUMA. SERVICES, `VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />........ ....... .......
<br />71"(/2024
<br />LINCOLN, NEBRASKA
<br />20240338
<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 DECEDE,(Jrt;..trast :first, Middle, Last, Suffix)
<br />Mii+hatei Jclhn .<Flaherty
<br />4� CIT1xANr?'STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, :Nebraska
<br />i S ictAL secuitITY NUMBER
<br />r
<br />9 506.36 8498
<br />8Rn FACIUTY.NAME Of not institution, give street and number)
<br />Grand :island. :Bickford Cottage L.L.C.
<br />ttaCITY OR1`OWN OF f EATH (Include Zip Code)
<br />:Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Sit STREET ANDNU1101ER
<br />::241.8 G€and Islartri Ave.
<br />9b. COUNTY
<br />Hall
<br />Sa>'AGE-LsstBirthday
<br />(Yrs.)
<br />87.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />$a. PLACE OF DEATH
<br />HOSPITAL ❑ inpatient
<br />❑ ER/Outpatient
<br />Q DOA
<br />1Ge. MAietAL STATt)a AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.. ATHER`S:NAM':E' (First, Middle, Last, Suffix)
<br />;:John Flaherty:
<br />MIDI.ARMED FORCES?
<br />(Yes, No, or Unk.) NO
<br />v 1$.,METHOD.OF DISPOSION
<br />w ;.� Burial Donation
<br />.E J Cremation Entombment
<br />'❑ Renovai` ❑ O'ther (Specify)
<br />Give dates of service H Yes.
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 08582' ..
<br />3. DATE OP:I7EAT .:(M :) IES
<br />June 1.t.10241
<br />6. DATE OF DI RTN (Mo., Days Yr.)
<br />AuguSt:18, 1938
<br />OTHER 0 Nursing Nome/LTC
<br />0 Decedent's Home
<br />® Other (SPeclfy)ASSISTED LIVING::::.
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Es E
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden Ilertt6
<br />Linda Kay Smithberger
<br />14a. INFORMANT -NAME
<br />Linda Kay Flaherty
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12 MQTHER'S-NAME (First, Middle, Malden Surname}
<br />Marguerite Pritchard
<br />13. EVER
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />TM : FUNERAL HOMe NAME AND MAILING ADDRESS (Street, City or Tiown, State)
<br />e• All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See!)ristructierliand examples)
<br />1e. PART I. Enter the chain of svents- diseases, Injuries, or complications -that 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 one line. Add additional lines it necessary.
<br />IM i0!1A00TE018Et$hi
<br />disease er aondlilon i'aaultifiQ
<br />In leatfit
<br />Sequentially , list conditions, If
<br />erry, iWIi.glik4.0e cau5*.:ibied
<br />oniinaa :..
<br />" I EN.erthew(PERLV84 . CA116E
<br />'p (dleeaae
<br />Or Willi/ that 1Ntiated
<br />1
<br />the events resulting in death)
<br />LAST
<br />a) Cardiac Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Kidney Injury Secondary to Poor Oral Intake
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Advanced Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />LIMITS
<br />14b. RELATION IMILATIONSHIPTil L1EOE11ENT
<br />Wife
<br />16c. DAT5(N1o,r.
<br />June 19 2l
<br />Nebraska
<br />18 PART it OTHER SIGNIRCANT CONDITIONS-Condltions contributing to the death but not resulting In the underlying cause given in PART I.
<br />'Chronic Congestive Heart Failure, Atrial Fibrillation, Essential Hypertension, Stage 3B Chronle Kidney Disease
<br />0 IF FEMAE;
<br />Ndtpre9naarrldrinpa tyear
<br />Pragnantitwheedfdeath
<br />❑ Nat pregnant but pingmint within 42 days of death
<br />��# ❑ Not pregnant, but pregnant 43 days tot year before death
<br />•Unlunown ifprepnsnt?!,IMin the past year
<br />go. DATE OF INJ(JRY (Mo Day, Yr.)
<br />224. INJURY AT WORK?
<br />YES.:.;.[INo....
<br />21a. MANNER OF DEATH
<br />® Natural LI Homileckts
<br />El El pendineyaattdetioa
<br />0 Suicide
<br />could not be determined
<br />22b. TIME OF INJURY
<br />Ilk :IF TRANSPORTATION INJURY
<br />DriverlOperator
<br />Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />19. WAS tila01 AL EICAMiN fR,,
<br />OR CORONER CQN'taetkD? `>
<br />YES el NO
<br />21c. WAS AN AUTOPSY?
<br />❑ YES Np
<br />21d. WERE AUTOPSY
<br />TO COMPLETE CAUSE
<br />❑YES; t
<br />22c. PLACE OF INJURY -At home, farm,street, factory, office building, con
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />I 22P; LOCATION OF INJURY STREET 8: NUMBER, APT.NO.
<br />h+t
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2024
<br />CITY/TOVYN
<br />23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />0.0 17 2024 08:49 A�1
<br />tad Ta the treat ofoty knowledge, death occurred at the time, date + nd place
<br />litid duatothe venial) stated. (Signature and Title)
<br />Alberto Solache Jr, MD
<br />R t04.0.CO USE..FONTRIBUTE TO THE DEATH?
<br />YES4NO ?:❑ PROBABLY 0 UNKNOWN
<br />AVAILABLE
<br />DEATH?
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d.11Mtli PRONOUNC
<br />24R. On the Dale of examination and/or kwailgldion, le ET/ ePlydan Gael
<br />the.tlme, date and place and due to the causes) stent (atfN! i
<br />26s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES IE NO
<br />r:NA1�**;'(8 AND AADDRESS OP CERTIFIER (Type or Print
<br />A erte:•Sotaah Jr, MD, 2444 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />‘9.-4.42.11 �as�ir ,moi r�
<br />26b. WAS CONI
<br />Not Applicable if 264
<br />28b. DATE FILED BYIREGISTiiiAR
<br />June 26, 20244
<br />amr,Yr.)
<br />
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