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5ti'/Yt4tt�.�ilta��rtr.dr�i)rGiy(�U{1�PA
<br />STAT_E OF NEBRASKA
<br />��}9rrryrrdPdtt `?ser44t711}Q1'1`ft5pa k errhriddddax o a.oi4e9A%t?IWP4x��..:.: ftrrrnrmtr. ter
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TIUE 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 />DATE. op fS$UAN E ..
<br />9/1/022
<br />LINCOLN, NEBRASKA
<br />202403866
<br />. ) J, iS.y' a %( c�'4 f/1,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4ECEIYENTsi34AME (carat,' Middle, Last, Suffix)
<br />Michael <#Ciera taYay
<br />4CITY AND ATE QR Teiterro Y, OR FOREIGN COUNTRY OF BIRTH
<br />Cp.Unci Bluffs, Iowa
<br />• SEICIAL 3EC.TfRITY #3U,MBER
<br />505-M8234
<br />5a. AGE • Last; Birthday.
<br />(Yrs.)
<br />8b..:ACfLUTY-N'AME (ifnlot Inetitudon, give street and number)
<br />96Q:$ Oak Street
<br />•
<br />8c.<Cl1Y OR TQ iiN Qr OaATH.(Include.Zlp Code)
<br />Granit Island (8801
<br />9a. RESIDENCE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8e.:: P LACE OF DEATH
<br />HOSPITAL ©inpatient
<br />ER/Ou patient
<br />DOA.
<br />l.:SrREETAIrp;;NUMeER: ..
<br />9S0 $ Oak Street
<br />taa:'MARriat4TATU3A'fTIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated [ Widowed 0 Divorced 0 Unknown
<br />• F.ATHER'S NAME (Filet, Middle, Last; Suffix)
<br />Donald Joseph Gray'.
<br />13.'Emu U S ARMED? RCES? Give dates of service If Yes.
<br />(Yes, No, or link) NO .
<br />15. METHOD OF D
<br />Creme#tat
<br />Resnovie""'
<br />POSITION
<br />DOrietion
<br />F#ttonil irnent
<br />Ottlttt.�Spectty}
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 12542
<br />3. DATE OF DEATH ()IIo.,
<br />September.6 2;022::::
<br />E. DATE OF SIRTii (Mo:, Day;Vi j
<br />Vovernbec;::2t,:4::9�6;:.:
<br />OTHER 0 Nursing Homo/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />P esptto Faol(tty
<br />INSI E C€TY ,001T,S .
<br />1t1b. NAMEOF SPOUSE (First; Middle, Last, Suffix) If wife, give mAlden Hams:
<br />Alice Marie Laursen
<br />12 MOTHERS NAME (First, Middle, Maiden Surname),
<br />GeDrOie:Oa Stuart
<br />14a. INFORMANT -NAME
<br />Alice Marie Gray
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />t t 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOMENAME AND MA LING ADDRESS (Street, City or Town, State)
<br />A)I Faiths: Funera(N'ame, 2929 S. Locust Street, Grand Island,;Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />. 16. PART i. Enter thedhain'of tivents- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory street, 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 />€ � IM(4EniATE 0Ai/9E($Itlat: a) Cerebrovascular disease
<br />`� , indaatd)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />seduemiahy usi candatons, 8 b)
<br />any, loading to tha.cauttq.liated
<br />Enter:;ttwuNt w1!tNt(GAusS
<br />((tisane:41' irdury:etiat Initiated
<br />the events resulting In death)
<br />LAST
<br />14b. RELATtONSI4IP 10 Seti
<br />Spouse
<br />180. DATE (AAo.,Ddy,:;
<br />Septerrlbef
<br />Nebraska
<br />11li ftp Coit
<br />8881)1`
<br />onest to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1$ pA.RTfl :OTHER SIGHiEICANT CONDITIONS -Conditions contributing to the death but not cast
<br />CdtpnatyArtery Disease; Schizophrenia
<br />20, Wf.EMALE :;
<br />Not prunewiddla pt
<br />tyt'egnRCYtc tttee ordeatii
<br />0 Not pi 4n' but iifitttiiint Within 42 days of death
<br />.0 _ Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown lt.vntynam witl!Itrthe pest -rear
<br />'DATE::.GF iltJtiRY(sio,€;;Day,'et.)
<br />22d. INJURY AT WORK?•
<br />CI YES •
<br />:pNO...,
<br />2
<br />216. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pendidg Inveatiggtidd
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />gin the underlying cause given In P
<br />21b0F TRANSPORTATION INJURY
<br />❑ Dnver/Operator
<br />p Pe(aaenger
<br />O'Petlestrian
<br />0 Other (Specify)
<br />onset
<br />PART 19, WASMf
<br />OR G4
<br />❑ Y.ES
<br />21c. WAS AN AUTOPSY'P
<br />0 YES
<br />21d. WEREAUTOPSY:fttiGNES A17AiiABLE>
<br />TO COMPLETEAUS £ OF DEATH?
<br />0 YES
<br />a
<br />22c. PLACE Or INJURY At hones, tarm, street, factory, office building, construction site,
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />. UrC/A'tii N.Dri1jlE i4jttt' k;STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 9, 2Q22
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />$eo eml er 1:2.2022
<br />3d, Te the beet ttf my ienowledee, death occurred at the time, date and place
<br />and due lofhe ttinte(s) stated. (Signature end Tide)
<br />Chad Vieth, MO
<br />23c. TIME OF DEATH
<br />11:30 AM
<br />28, Dip TOBACCQ U$E CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />VES :0 Nti PROBABLY
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the bsais of examination end/or Investigation, in my opinion death oadtirred at
<br />the tlme,'date and place and due to the cause(.) stated. (Signature ant Title)
<br />®UNKNOWN
<br />0 YES NO
<br />1 NAME,iEITLEA+Nt;1AD4KES8 Or CERTIFIER (Type or Print
<br />GlitaNiettt MCV2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />at '2a J7
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2022
<br />
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