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<br />,1Aa
<br />fr4l, ; STATE OF NEBRASKA
<br />.,.errttggNfi,v t46(QyiMifllser;;;saitp, �r,°••eatr141$1Y.ItN1»,"".•.vy,rr rce_<
<br />.t HEN :THIS COPY CA RIES THE RAISED SEAL OF STATE OF. NEBRASK q iT CERTIFIES THE DOCUMENT BELOW.
<br />:Blir A'TRUE clap) "'OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND -
<br />''HUMANSERV/CES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />a
<br />DATE ' OP I,I14)UCE
<br />7/25/24
<br />LINCOLN, NEBRASKA
<br />202405515
<br />SARAH BOVINE
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE Q.F. DEATH
<br />1:- DEOEDENT*$-SAME (Feet* Middle, Last, Suffix)
<br />Patrick :<Rebecca McCue
<br />4..CIT AND:STATE'OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wilmington, Delaware
<br />I SOCIAL sECURID(NUM
<br />22248-0869. '`:
<br />BER
<br />5t: AGE = Litt Birthday
<br />(Yrs.)
<br />80.:.
<br />tiff, FACILITY-NAME`Of not Institution, give street and number)
<br />Tabitha. at Prairie Commons
<br />SC' CITY:OF ':* .I1 4F;:DEATH (include Zip Cods')
<br />Islan68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />91,. woken *to :NUMBER
<br />2535Idaho :Avenue
<br />9b. COUNTY
<br />Hall
<br />10a:'IYIARITA4 STAtUS AT TIME OF DEATH (l Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11'<;F1l HSR'S=NAl(E:'(Flrst, Middle, Last, Suffix)
<br />Mieatsi.<.: Ritay: <:Jr
<br />13rEVER IN U.S. AHME 1,FORCES
<br />(Yes, No, or Unk.) No
<br />48, METNOD:.OF
<br />Burial
<br />SA,O.SITIQN
<br />Donation
<br />Crentat1oti l j.Etitombment
<br />©'Remove('` ❑`ON»r (SpecHy)
<br />lye dates of service If Yea.
<br />613, UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL.. ❑'Inpatient
<br />HOURS
<br />MINS.
<br />March � 1
<br />OTHER ® Nursing Home/LTC
<br />❑ ER/Outpatient 0 Decedent's Home
<br />❑,DOA 0 Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mouton
<br />Robert Lee McCue
<br />I1t. MOTHER'S -NAME (First, Middle, Malden
<br />Patricia Smith
<br />14a. INFORMANT'NAME
<br />Robert Lee McCue
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />10b. LICENSE NO.
<br />1537
<br />CITY/TOWN
<br />Stockton Cemetery Stockton
<br />17a, FU;HEft4L;;HOME;;NAME AND MAILING ADDRESS (Street, City or Town, S
<br />Afel Funeral Home 1123 W. 2nd, Grand Island, Nebraska
<br />)
<br />CAUSE OF DEATH (SOee,Inatrtictiona and examples)
<br />PART I. Enter twichain Of wenta• ,dilaau d, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory amat, or vintriculer fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />e'real ;; ;! Send d stage Alzheimers Disease
<br />Far conditofi'tWittIng
<br />Sequentially List conditions, it
<br />ilitry Iaadleg ta:the m nise.aated
<br />on i1rie x!.,
<br />Eittir.ttti UN ER(.YING CAUSE
<br />(dlseiwe or injury twit tilklated
<br />.the wants rwiuhing in death)
<br />LAST
<br />tit:: PArt'!'n. 0THE.R
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />NIfICANT CONDITIONS -Conditions contributing to the death:but not'resultitigtn the underlying cause given In PART!.
<br />20,.1 P(Mt1ALS .;;
<br />N01 Pna .tit Witi 'past: year
<br />.. .:::..
<br />efignuii at;trda if der to
<br />E intpregn int, buf.prapnent within 42 days of death
<br />0 Not prlgnant, but pregnant 4t days tot year before death
<br />LlMpaenq;R:pt41400. t!,11,kn twi peat freer
<br />isDA) iOF)NJUR
<br />22d. INJURY AT WORK?
<br />CYESs ::D NO::::
<br />Yr.),
<br />21a. MANNER OF DEATH :.
<br />Natural Homicide
<br />❑ Accident 0 Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLA
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />1nc4:019NJIII Y' 'STRE€T& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 8, 2024
<br />23b..DA, S r3NED (filar, Dal+, Yr.)
<br />JuIY` )824
<br />ad;:To tl a bait gt:tay,knowledge, death occurred at the time, date and place
<br />grid due Ca tM caurp) Meted. (Signature and Me)
<br />Jana.G Van Wie, MD
<br />23c. TIME OF DEATH
<br />01:20 AM
<br />2& DID fOM USE ONTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />TLS !''.1F.A'At MSS OF CERTIFIER (Type or Print
<br />iVitOWte, MD, 3563 Prairieview St, Ste 200, Grand Island, Nebraska, 68803
<br />21b.:IF TRANSPORTATION INJURY
<br />i t lve/Operator
<br />CIPassenger
<br />Q Pedestrian
<br />El Other (Specify)
<br />OF (NJURYUU hOma, farmk street, factory, office building, conab'Ul
<br />1
<br />I?
<br />21c. WAS AN AUTYPS'i F
<br />(3 YES
<br />21d. WEkeAwt
<br />TOPLIte:
<br />❑ YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b..TIME 'OF
<br />24e f n the basis of examination and/or investigatbm
<br />ih6:time, data and place and due to the ceusets)'s.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES : NO
<br />16b. WAS
<br />Not Applicable If 20a
<br />29b. DATE FILED
<br />July 22, 202
<br />TE0i'
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