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<br />STATE OF NEBRASKA
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<br />WHEN. THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA,'iT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE cper OF THE ORIGINAL RECORD ON FILE WITH :THE NEBRASKA : DEPARTMENT OF HEALTH AND
<br />.:HUMAN SERVICES > U7TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF /SSUA NDE
<br />6/12/2023
<br />LINCOLN, NEBRASKA
<br />202500240
<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 />1, DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Gary : Lee , Pearce
<br />4. CITYAND STATE: OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7•. SOCIAL SECURITY.NUMBER
<br />�a07 54.4575
<br />0 86 FACILITY NAME:(lf:not Institution, give street and number)
<br />CHI Health St. Francis HMS
<br />5 8c, CITY OR TOWN OF :DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />u) Nebraska
<br />9d.STREET AND NUMBER
<br />4172 Redwood Court
<br />9b.COUNTY
<br />Hall
<br />Sa.AGE - Last::Birthday
<br />(Yrs.)
<br />10e MARIT•
<br />AL: STATUS: AT TIME OF DEATH ® Married 0 Never Married
<br />es❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.;FATHERS-NAME (First, Middle, Last, Suffix)
<br />Walter Ellis Pearce
<br />13, EVER IN U 8, ARMEDFORCES? Give dates of service H Yes.
<br />s (Yes, No, or Unk.) Yes 10/05/1965-10/04/1971
<br />u 15. METHOD OF DISPOSITION
<br />.: Burial ❑ DOr1ation
<br />Cremation © Entombment
<br />Removal. Dottier (Specify)
<br />sit
<br />vi
<br />p
<br />> 3 aro., the uNOEIHLYING OAU$E
<br />• 15 (disuiseeorinjutyilhatinhkted
<br />77
<br />64, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL: Inpaitfeent
<br />❑ ER/Outpationt
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 07728
<br />3. DATE OF DEATH (INo., Day, Yr,)
<br />June 6, 2023
<br />6. DATE OF BIRTH (Mo., caw 'Yr.)
<br />July 10, ;.1945a ::,:
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Doccdent's Homo
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑Hospice Fe:ciiity
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) Ifwife, give maiden nami
<br />Irene D Siuda
<br />11DB
<br />YES
<br />LIMITS
<br />❑ NO:,:;
<br />I12. MOTHERS -NAME (First, Middle,
<br />Margaret Ann McCredie
<br />14a.INFORMANT.NAME
<br />Irene D Pearce
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE Ma., Day, Yr.).
<br />June 6, 2023
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Wei Funeral Home, 1123 W. 2nd, Grand Island, Nebraska : •
<br />CAUSE OF DEATH (See::)nstructlons'and examples)
<br />18. MART I. Enter the chain of events- diseases, 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 ono cause on a line. Add additional Tines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAtl*E (rinai a) Cardiorespiratory Failure
<br />din,.Ease or condition fe*uf)up:
<br />In Naath)`:
<br />Sequentially Hit conditions, B
<br />any, leading to the cauee listed
<br />on Uhl a.
<br />the events resulting in death)
<br />tag LAST
<br />0
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />blAcute Hypoxic Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Non ST segment elevation Myocardial Infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Gastrointestinal Bleeding
<br />i7 lB PART H; OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resuiting In the; Underlying cause given in PART!.
<br />Acute Renal Failure ,'Heart Failure with reduced ejection fraction, Severe sepsis Secondary to acute cystitis with hematuria,
<br />to Hypernatremia
<br />6 20. IF FEMALE:
<br />. ❑ :Not pregnant Within past year
<br />.g ❑ Pregnant at'hew ofdeath
<br />.
<br />s&F ❑:. Not pregnant, but pregnant within 42 days of death
<br />A❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />C ❑ .Unknown If pregnant wihin the past year
<br />.$ 22a. DATE OF INJURY (Mo., Day, Yr,)
<br />g 22d. INJURY AT WORK?
<br />b ❑ YES ❑ NO
<br />eh.
<br />.
<br />21a. MANNER,OF DEATH
<br />® Natural ❑ Homicide
<br />•
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />.: Passenger
<br />•❑ Pedestrian
<br />❑ Other (Specify)
<br />22c. PLACE:OF INJURY.At liotile, farm,
<br />17b Code
<br />6880'i >
<br />APPROXIMATE INTERVAL
<br />OAa.ttO del .:
<br />Minutes
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILADtS
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES CI NO
<br />set, factory, office building, construction site, etc.:i
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2f. LOCATION:OF INJURY':. STREET 6 NUMBER, APT.NO. CITY/TOWN
<br />23e. DATE OF DEATH (Mo„ Day, Yr.)
<br />June 6, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 8 2023
<br />23c. TIME OF DEATH
<br />12:54 PM
<br />3d. To ilia beat of niy anowiedge, death occurred at the time, date and place
<br />• and duo to the:c*uae(s) stated. (Signature and This)
<br />Venkata S Kanakadandi, MD
<br />s
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD;:::..
<br />24e. On the: basis of examination and/or Investigation, in my opinion death dttairred at
<br />the tidte, date and place and due to the cause(*) stated. (Signature 'Oates)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Venkata'S Kanakadandi, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR SSUE DONATION BEEN CONSIDERED?
<br />DYES 14 NO
<br />26b. WAS CONSENT GRANTED?. ,....
<br />Not Applicable if 26a is NO ❑ YES
<br />0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 8, 2023
<br />d
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