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STATE OF NEBRASKA
<br />WHEN THIS S' CAARIES THE RAISED SEAL OF STATEOF.:NEBRASK >IT CERTIFIES THE DOCUMENT BELOW T
<br />>: `B3E,4'TRUE.CQ YiOF>THE ORIGINAL RECORD ON FILE WITH; THENEBRA'SKA:.. DEPARTMENT OF HEALTH AND'
<br />• HUMAIW'SERtVICE& VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />7/29/2024
<br />LINCOLN, NEBRASKA
<br />202.40501"
<br />SARAH BOHNEN
<br />ASSISTANT STATE REGISTRA
<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:;:(First, Middle, Last, Suffix)
<br />' C fg ::! FAO:: :'>Mead
<br />4s 4kV'AND'STATE"OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand. Island,.: Nebraska
<br />:2SOCIAL SECUI:t rt:NUMBER
<br />Ste. FACIUTY44AME (if not Institution, give street and number)
<br />.:CHI Heatth.S.t: .Francis
<br />8F<CtTY;:OR TOWN;:OP:DEATH (Include Zip Code)
<br />Gt red` stand'; 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />sill,:sT1 EE7'AND NUMBER
<br />> 71:1;;VVe lnu t Street
<br />9b. COUNTY
<br />Hall
<br />10a MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1.1 FATHER
<br />RO:lald::>.
<br />aMe
<br />Mee
<br />t, Middle, Last, Suffix)
<br />E I R IN U.S. AEIMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) No
<br />4INETHO C F p)SPASITIQN
<br />IX aural <; : ;;❑`Donation
<br />Crenniluott >:Eitombntent
<br />❑`1lemovar ' : ❑Othar (Specify)
<br />Sri. AGE" Last Birthday 6b. UNDER 1 YEAR
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />72
<br />Bit. PLACE:QF i?goti
<br />HOSPITAL. ® Inpatient
<br />❑ ER/Outpatisnt
<br />❑ ..DOA
<br />9c. CITY OR TOWN
<br />Wood River
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />6. DA
<br />:: Jki0
<br />024
<br />BIRTH (Mo jti
<br />Janut r> :> 1.g52: :
<br />OTHER 0 Nursing Horns/LTC
<br />❑ Decedsnri Home .
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE(First, Middle, Last, Suffix) NW*, glvs motion
<br />Susan Moritz
<br />12. MOTHER'S -NAME (First, Middle, Mal
<br />Gladys;:F Roberts
<br />14a. INFORMANT -NAME
<br />Susan Mead
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18b. LICENSE NO.
<br />1537
<br />led. CEMETERY, CREMATORY MOTHER LOCATION' .;: . CITY / TOWN
<br />Wood River Cemetery Wood River
<br />17a. TUNER$ HOME NAME AND MA LING ADDRESS (Street, City or Town, SW")
<br />F:u;neral<lome, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />tf, PART I. Enter tthe.chahi o} Svelte- dlpeasss, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or veMrlcutor f9xitation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional fines if necessary,
<br />IMMEDIATE CAUSE:
<br />eiRespiratory Arrest
<br />r co uttan re.4Mflp
<br />In drathl DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially the conditions, if b) Cerebral Hypoperfusion
<br />sftw Iesdtn9 to tin catta.Jsned
<br />dir:line.e:.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />E ta(thit N ERL'INGS1USE. c)CardiacArrest
<br />.::...lewd
<br />(drN'iise or MOO/ the*
<br />the events resulting 1"1"" DUE 70, OR AS A CONSEQUENCE OF:
<br />tAST .. ......_ d)Choking
<br />1:a::PART 11:>QTHEI salt IFICANT CONDITIONS -Conditions contributing to the death but:not rasultin
<br />PParicinson`s disease, hyperlipidemia, bipolar disorder
<br />2b.;aW:FEMA1
<br />..Notps.gns t dthtnpt4year
<br />0 PtwYld}R:Iit::li[[lCilEt:lrtltF
<br />Nat pt'ori'rrant, but 1 ignerd within 42 days of death
<br />0 Not pregnant, put pregnant 43 days to 1 year before death
<br />4nknown:!ifpre9nant:whhin the past yea
<br />11 DA E tit INJur .Y:(P60., Day, Yr.)
<br />21a. MANNER OF DEATH:.
<br />E Natural Hondclds
<br />0 Accident ❑'Psndingtnveatipition`
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c..FLA
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TION 0 INJ.LIOY - STREETS, NUMBER, APT.NO.
<br />DATE;©F DEATH (Mo., Day,Yr.)
<br />ulv 19 2
<br />23b..DATE::.EIGNED (
<br />aay.
<br />CI
<br />ath occurred at the time, date and place ::: ::'
<br />(Signature and Title)
<br />TE TQ THE DEATH?
<br />PliiieAKY 0 UNKNOWN
<br />underlying cause given in PART L
<br />21b. IF TRANSPORTATION INJURY
<br />DrivarlOperator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />10c. DATE(Mo,•.riI
<br />July2 r ll r
<br />OF INJURY-Atlroime, farm; street, factory, office building, conetrtiOtin 4trs
<br />N
<br />STATE
<br />_ } 24a. DATE SIGNED (Mo., Day, Yr.)
<br />;C11 y1;Xt)Blk U$E;CONTRiBU 28a. HAS ORGAN ORTiSSU,E DO
<br />0 YES lifj NO
<br />27 NAME -kiln. AND ADO EBB OF CERTIFIER (Type or Print
<br />Matthew Day, MD, , 2620 W Faidley Ave, Grand Island, Nebraska, 8803
<br />28a. REQ18TRAITS 'SIGNATURE ,
<br />34,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24s, Gil 1FR bests of examination and/or invsatlgatbf,-hi
<br />tine, data and place and due to the cause($ it
<br />TION'BEEN CONSIDERED?
<br />De Din' LeNTe
<br />
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