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STATE OF NEBRASKA
<br />%yrr,,,,e x rkRS ¢!t6 t y" a41,m/OA , ri 4,4,91tYA`ige)!1,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO.
<br />8E A TRUE COPYO.F>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 />PA TE OF ISSUANCE
<br />7/12/26i4
<br />LINCOLN, NEBRASKA
<br />202403435
<br />SARAH BOEN N1A
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES.
<br />.00104)40)
<br />.VDECODENTS•NAWIFirst, Middle, Last, Suffix)
<br />Robert Alien 'Grist
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4,•C1159 ANOSTATE'CM TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Stratton).Colorado
<br />7, SOCIAL SECURITY NUMBER
<br />508-64..3780
<br />Bas AGE LIMB' idly
<br />(Yrs )
<br />80,
<br />8b.'FACILITY•NAME'(lt not Institution, give street and number)
<br />1809 S.:.:Ingalls, Street
<br />Sc CITY OR TOWN OF.DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Se. RESIDENCE -STATE
<br />Nebraska :.
<br />8bi UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />O. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />24
<br />S. DATE OF 'DEATH (ttro4iINi
<br />Junta 30, 24 •
<br />...i;:
<br />8. DATE OF BUt114 (Mo., Otey; Yr.)
<br />OTHER 0 Nursing Home/LTC
<br />RI Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />8d >I;'rnget l pmeiMBER
<br />18.0$ S ; ItagaPs Street
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />De. APT. NO.
<br />40t6i4ARITAiBTATOS AT TIME OF DEATH ® Married 4 Never Married
<br />Q Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11'.FATNER-NAME (Flrst, Middle, Last, Suffix)
<br />Heron Edward ;Grist
<br />13.• Et/ERIN :8 ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />IS.,AMETHooOF DISPOSITION
<br />(;Q Burial ; jint3tiilason
<br />® Crenlatte n i Entaihbment
<br />[ 'Rernova' [ 'bther(Speclfy)
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give
<br />Jean M Laughlin
<br />12. MOTHER'S -NAME (First, Middle, Maiden
<br />Poxe Irene Monroe
<br />14a. INFORMANT -NAME
<br />Jean M Crist
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />186. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Farths. FuneralHome, 2929 S. Locust Street, Grand Island, Nebraska
<br />14b. RELATk
<br />Sp9u5e'
<br />1Sc OATS (Mo.,
<br />July 4' 2
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />PART L Enter the chain of events- 'dieeans, injuries, or complications.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular tibriliatlon without showing the etiology. DO NOT ABBREVIATE. Enter only lone cause on a line. Add additional lines If necessety.
<br />IMMEDIATE CAUSE:
<br />a) respiratory failure
<br />I • ED1A1'E Gftil :(pf!aY
<br />":10#404010.(00003).);),•:••ay
<br />Sequentially Est conditions, if
<br />1el1 Igdina:TMY:the gNf#4:U.eted
<br />ons,re a
<br />attheUANDERLI$GGAtisE
<br />idlsiwee ti $uY1+ thattiliiiated
<br />the events rssuEMg in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)lung cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1S :PART It OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the fleett but not reaulting in the underlying cause given In PART I.•
<br />gciyrrryaigia rhetlmaUr;a .
<br />,.2o.;:WCEMAl.E
<br />:.0 Not pregnant wlthtnpaat:ysar
<br />Pw at AE Ema o►darili
<br />•tr.! ►)d pregnant, 04H A00.10 *OM 42 days of death
<br />Not pregnant; bid pregnant 41 days to 1 year before death
<br />tkknown.B prey reat.wi hin the pest year
<br />2 tit; DACE f?F;(NJURY(NIo:, Day; Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident j Pendinglnvestigtitlon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />:< : ;0 TES :ONO
<br />21b. IF TRANSPORTATION INJURY
<br />OfiverlOperittor
<br />© rinanger
<br />Pedestrian
<br />Other (Specify)
<br />19. WA
<br />22c. PLACE OF kNJUR .At hom0, tans street, factory, office building,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />226.LOCATION OfSCOW STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />23a. DATE OF DEATH -(Mo., Day, Yr.)
<br />June 30, 202.4
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TNME OF
<br />23b.:DATE..SIQNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Drily 3j 2tt24 10:00 PM
<br />lin pent o#pty lnlowNWge. death occurred at the time, date and place
<br />dpe ie !tie esoaa(itetsted. (Signature and Title)
<br />Isaac J. Berg, MD
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2/e On iliabasisof examination enWo,hv../lgaSen;1nmy
<br />:':. alis tans, date and place and due to the eines(e)
<br />24;AI0 7OBA +O tlSE rvONTRIBITrE TO THE DEATH? 26a. HAS ORGAN OR T15$UE DONATION BEEN CONSIDERED?
<br />N °;.PROBABLY El UNKNOWN OYES El Nev':'
<br />,N/II °tzq T lTl>�akND ADD ESS QF CERTIFIER (Type or Print
<br />80 J `Berg MD, 729' North Custer Avenue, PO Box 2339; Grand Island, Nebraska, 68803
<br />28b. WAS
<br />Not Applicable; If 2ba.
<br />28b. DATE FILED.
<br />July 8, 2024
<br />
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