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111
<br />. " •
<br />wkigi).
<br />STATE OF NEBRASKA
<br />0041,607,0
<br />,
<br />WHEN itlioopproopEs THE RAISED SEAL. OF STATE OF NEBRAsgktrtgRrm CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE c0iFY 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 ISSUANCE
<br />8/19/2024
<br />LINC&N, NEBRASKA
<br />SARAH BOHNENKAMP
<br />2 02 4 0 at 3 9 6 DEPARTMENT OF HEALTH
<br />ASSISTANT STATE REGISTRAR
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Mill10011
<br />• :]].R voecetkeNrS,NAME(strst, Middle, Last, Suffix)
<br />„„„
<br />2. SEX
<br />Male
<br />3. DATE OF DE&TH..(
<br />August 3:.20.24
<br />24 40922:-
<br />4. CITY AND STATE art TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />i9a. RESIDENCE -STATE
<br />Nebraska
<br />.HastingsNebraska
<br />54..AGE - Last Birthday'
<br />(Yrs.)
<br />75 .:
<br />WUNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />-.••••••••-..,••••••••••••.:•.•-•••-••.:••.
<br />DAYS
<br />HOURS
<br />MINS.
<br />t DATE OF BIRTH (Mo.,
<br />August 10:1948
<br />7 SOCIAL SECURITY tosses
<br />58 Or365
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />0.171t tteelth St,:Francis
<br />86.•PITY•OftitifVft•OP DEATH (Include Zip Code)
<br />Island. 68803
<br />ticETREETAND3#0000
<br />18145 FreedomDrive
<br />Sb. COUNTY
<br />Hall
<br />ite PLACE:OF DEATH
<br />. „HOSPITAL: •00.Inpatient
<br />U ER/Outpatient
<br />000A
<br />•
<br />ioettAiinkEiTATuSAT TIME OF DEATH gi Married 0 Never Married
<br />2 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />e 1 ATHER'$•41AMEAFIreit, Middle, Last, Suffix)
<br />• " ' 07iaO a:i:iSdhfaChter
<br />13.EVERINU4. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes • 1967-1971
<br />t.) i& se.:hloovs. DISPOSITION
<br />C Burial i:t*stion
<br />E crp,;440.4 0eopiiibm•nt
<br />066,r(apeciti)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OThER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />o Other (Specify)
<br />I 8d. COUNTY OF DEATH
<br />I Hall
<br />le. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />'Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Gloria Kay Wyssman
<br />1
<br />.;....;: : 12.150THERIte:NAPAE (First, Middle,
<br />: • G oria . Smith
<br />14a. INFORMANT -NAME
<br />Gloria Schlachter
<br />16s. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />14..f.ygoptiwtioymWsME AND MAILING ADDRESS (Street, City or Town, Abdo)
<br />AU FaltheiiFunaratitiome, 2929 S. Locust Street Grand Island Nebraska
<br />•
<br />16b. LICENSE NO.
<br />CMY/TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examoles)
<br />*VISSIPP:-.911YAMOOt
<br />maiden mini"
<br />•
<br />Maiden ••)•Qi.
<br />4$. PART I. Enter the chain of events- -theriases, 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 If necessary.
<br />EM. Muttiorgan Failure
<br />f• dha.a.OcwiltlQnr$*Uttht5•
<br />In death) •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />BsfivenfliitlY UM conditions, if b)Severe Sepsis with Septic Shock
<br />any, feeding WSW CMOS Riled
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />•Ens the UNDERLYIMQCAUSE C)
<br />(dieeaee or injury that
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST •
<br />d)
<br />.21111 •
<br />15. PARtS OTHEK:.81OHIFICANT CONDITIONS -Conditions contributing to the death:butnet reetientlit.- Ote.tinderlyirig cause given In PART I.
<br />Acute:newt:au:qv:Fakirs, Acute Kidney injury, Acute Encephalopathy, -ChoInglocarcintiMa •
<br />... •
<br />,,.„...:.x jallo:.,.vo,0001,wIp4ppt)!..ear
<br />!]•••ikca::-. '0I.FtWif...est#Tiltt#8A;AilI"•
<br />•••••4 treat Pregnant, btit"prognard within 42 deys of death
<br />•• • 0 NOt pregnant, but pregnant 43 days to 1 year before death
<br />.. ..,: Qunknevnifeeetemetlein.the past year
<br />(!)1.#.:;', Day. Yr)
<br />22d. INJURY AT WORK?
<br />YES 0 NO
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident Pending investigation
<br />Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />214, IF TRANSPORTATION INJURY
<br />ID Sayer/Operator
<br />C. iteesenger
<br />El Pedestrian
<br />0 Other (Specify)
<br />14b. RELATIONSHIP TaimciDENT7
<br />Spouse
<br />isc.DATE.1!4; E#y;
<br />Auaust� 2024
<br />•
<br />Nebreska
<br />-1 APPROXIMATE
<br />•
<br />onent
<br />*nisi 63 ciesth
<br />{Days.....
<br />onesglot$eAth
<br />IL WAS MEOW* InvogEl...
<br />OR .CCI 0: *00D?
<br />0vsNo•:. .
<br />21c. WAS AN AMTI3ftYPeputpomeo.?
<br />Dyes , NO
<br />21d. WERE AUTOPSY POMENOS AVAILABLE
<br />TO COMPLETE CAUSE OF DEEMS
<br />veQs
<br />22c. PLACEOPINJURYAtITOMeatinti,etreet, factory, office building, construction sittit8.4'
<br />•
<br />•
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221' 1-004.trOppfj#00,..*. STREET & NUMBER, APT NO
<br />X '
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />z
<br />August 3, 2024
<br />23b,0ATE•AIDHED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />09:4 AM
<br />,T*01.300.0intrentivitedge, death occurred at the time, data and place
<br />pl catefAtaaif ceueete) steed. (Signature and Title)
<br />Suresh.ManaDuram, MD
<br />i*RP19. PROBABLY 0 UNKNOWN
<br />IMMO USE:CONTRIBUTE TO THE DEATH?
<br />NO C
<br />0 YES
<br />/74405,k• OS OF CERTIFIER (Type or Print
<br />EUreshMenapuram, MD, 2620 W Faidley Ave, Grand Island," Nebraska, 68803
<br />........
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />241a. raw oP
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME
<br />.•.
<br />24•,,Ontbe basis of examination and/or Investigation, In my
<br />the tinte, date and place and due to the causMstraated.
<br />26a. HAS qucAucansSUEDONATIDNEEEN CONSIDERED?
<br />YES Capp
<br />211a. REGISTRAR'S SIGNATURE
<br />:::•••
<br />•••-•::••••••••••••••,
<br />• Th
<br />28b. WAS CONSENT
<br />Not Applicable If 26a le
<br />• /
<br />28b. DATE FILED AWKEDISTA65ififftlfteDif&:7!;/. .3.
<br />August 13,
<br />
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