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„K STATE.OF NEBRASKA .... ..
<br />uudJccu�, - a>....,,,y2.SritiWOtdCaas� ::::•4tiiiiti'ItfiHaa.s-... _sy
<br />THIS COPY CCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />A' TRUE COPY OF"THE,ORIGIINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE ©FISSUANCE
<br />8PIC2024
<br />NEBRASKA
<br />202406269
<br />AR BOHNEN1A
<br />ASSISTANT STATE REG
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DENTS- iddle, Last, Suffix)
<br />Richard "t ee...Brown
<br />'0I1Yi4ND'STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />AI(lance:.:Nebraska
<br />JAL SEGURVIY`'iepleER
<br />RE$IDENCE*8TA
<br />Nebraska
<br />, give street and number)
<br />Jude Zip Code)
<br />912. COUNTY
<br />Hall
<br />10ia:`iYIARnAELL TAUS AT TIME OF DEATH ® Married 0 Never Married
<br />Nettled, but sepekv 0 Widowed ❑ Divorced ❑ Unknown
<br />EVER H9 U.S. ARMED FORCEt# Give dates of service If Yes.
<br />IYm No, or Ua:ki,Iw
<br />a. AGE - Last Birthday
<br />(Yrs.)
<br />69
<br />6b. UNDER 1 YEAR
<br />a. PLACE OF DEATH
<br />HOSPITAL. Q Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />3
<br />OTHER IE Nursing Ifoms/L'
<br />❑ DecsdanIs
<br />❑ Other(SPeedy)
<br />ad. COUNTY OF DEATH
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give
<br />Gwenlvn West
<br />12. MOTHER'S -NAME (First, Middle, Mai
<br />II Arlene Marie O'Connell
<br />14a. INFORMANT -NAME
<br />Gwenlvn Brown
<br />16a. EMBALMER -SIGNATURE
<br />on Not Embalmed
<br />d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />iERA4;.HON13'NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />I;-FIrf1►rat:ttaitae, 1123 W. 2nd, Grand Island, Nebraska
<br />(dlitit' P.
<br />�UNDERLY1NG'4Ula
<br />or tn)u6thbl hNtlatsd
<br />p resuJtM g In d.atb)
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />5- raleeases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ar flbHaation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional !Ines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardio-Pulmonary Arrest
<br />TO, OR AS A CONSEQUENCE OF:
<br />ereditary Spastic Paraplegia
<br />OR AS A CONSEQUENCE OF:
<br />0, OR AS A CONSEQUENCE OF:
<br />R. ION CANT CONDITIONS -Conditions contributing to the death but not resulting in Its underlying cause given in PART I.
<br />hitt 42 days of death
<br />days tel 1 year before death
<br />e east veer
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />Q Accident Q Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />C] DHver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At horns, farm, street, factory, office building,
<br />SCRIBE HOW INJURY OCCURRED
<br />T 3 NUMBER, APT.NO. CITY/TOWN STATE
<br />ay, Yr.)
<br />b. DATE SIGNED (Mo ,Dap, Yr.) 23c. TIME OF DEATH
<br />1Q:28 PM
<br />3 fiti; .; of ray , death occurred st the time, date and place
<br />';'.:; :I:to the t assets) st tea, (Signature and Title)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2N, OA But basis of examination and/or InvestgtetlNt, In MP_
<br />the time, data and place and due to the cause(e) Iltt6ee.
<br />11 SE COW B TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />BLY ® UNKNOWN 0 YES Ida NO
<br />AND:AODl 6 CERTIFIER (Type or Print
<br />Fago. D, 2b5 S Lincoln Ave Ste 101, York, Nebraska, 68467
<br />26b. WAS CON
<br />Not Applicable if
<br />211b. DATE FILET
<br />August 6,
<br />I/trill I
<br />4.
<br />
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