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<br />STATE OF NEBRASKA_��
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<br />WHEN TF S COR CARRRIES THE RAISED SEAL OF STATE OF:NEBRASKA,:'lT CERTIF#ES THE DOCUMENT BELOW TO
<br />BE A".TRUE COPY,OF'1 HE 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: OF ISSUANCE
<br />12113/2024
<br />LINCOLN, NEBRASKA
<br />I. Dactoet s•NAME iFirst : Middle, Last, Suffix)
<br />Patrick Michael` `:.t'Neill
<br />202501518
<br />51z4(J
<br />&4
<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 />CERT!F!CATE OFDEATH..
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />;: Grapdisialld. Nebiaska
<br />AL SECtiR V
<br />1:: 8156 s
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br /><` 281:5:W. John St eet::
<br />c. 'Mil OR:TOVVII'.QP DEATH (Include Zip Code)
<br />Grarld'Ialandl ' 68803
<br />9a. RESIDENCE -STATE
<br />:: Nebraska
<br />Ed STREET AND NUMBER'
<br />2515. W John Street
<br />9b. COUNTY
<br />Hall
<br />1ga. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Marred, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />f1 FRTHERS,,.NAME :(:first;.: ; Middle, Last, Suffix)
<br />G6tdo(i
<br />3. EVER IN U.B. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, Or Unk.) yes 09/21 /2000-03/25/2005
<br />.i5:MEfl::Qn.OFD(SPOS TION
<br />Jj'Si mretion Q Entimrn mant
<br />0 Removal 0 Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />43.
<br />bb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PIACE OF DEATH
<br />HOSPITAL :.❑ Inpatient
<br />(3 ER/Outpatient
<br />DQA ....
<br />9c. CITY OR TOWN
<br />Grand Ryland
<br />HOURS
<br />MINS.
<br />24.1:6580 . .
<br />3. DATE OF DEATH: Mo., Dt y,.Vr:):'
<br />November 29 2024. ,
<br />6. DATEOF BIRTH (Mo., Day, Vr.)
<br />March 16, 1
<br />OTHER 0 Nursing HomeILTC
<br />l Decedent's Hoare
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e.:APT. NO.
<br />91. ZIP CODE
<br />68803
<br />981
<br />91a'tN6tOE Cfl LtMrr8:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Keisha :. Nehls:::
<br />14a. INFORMANT -NAME
<br />Keisha O'Neill
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />1Z MOTHERS -NAME (First,
<br />: ':;Colleen:;:: Halpin
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Tiff, FUNERAL. HO tE,NAMEAND MA UNG ADDRESS (Street,'Clty or Town, State): ..
<br />> ; All Faiths Fursera `Hone, 2929 S. Locust Street, Grand Island, ..Nebraska
<br />18b LICENSE NO.
<br />1.454
<br />Middle, Malden Surname)
<br />CITY/TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />tL PAIIT I, Enter the chain of events- diseases, injuries, or compllcanons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />reepintt ry arnst, or verl(ritular fibrillation without showing the serology. DO NOT ABBREVIATE. Enter only one cauas on a line. Add additional lines if necessary.
<br /><. :IMMEDIATE CAUSE: t Respiratory Failure
<br />:110As •rE CAIa6E .e
<br />aaaq;;tir:;Citdatcn sulfIYp;
<br />M death)
<br />s}auentieily. list condidone,.lf:.
<br />isedIna` .theeiteee:iintig4:
<br />::art SnI
<br />Interitis:3(1VGERLVISKItAljet.
<br />(disease or Injury that initiated
<br />tine everts misname In death)
<br />DUE TO,,OR AS A CONSEQUENCE OF:
<br />b) Pancreatic Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />d)
<br />18. PART t1THE t:SIGN(FICANT CONDITIONS -Conditions contributing to the death but Oct resulting in the Underlying cause given in PART I.
<br />22la::.'IF FEiNl'cI.E:'
<br />Yittt *t preilnt:P(ttfln:pt ym:::
<br />?? � Esenant' t dm•: tf deet+.r:::;'
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />4nitnoa,!i 1pr•4+.int4thb:ltepoetveer
<br />225. DATE t F< eLIDAY:(MO, ;;.D..ay, Yr.}
<br />22d. INJURY AT WORK?
<br />21a. MANNER OF,DEATH,
<br />Natural ❑ Homiyhle •
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />•21b4tr:T#'tA.NSPORTATION INJURY
<br />❑: bris tdCperetor
<br />Paeeanger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELAT#ONSHIP TO DECEDENT
<br />Spouse
<br />lac. DATE (MoDayYr)
<br />December k2024
<br />**ATE
<br />Neibreska
<br />17►s':2
<br />68801.:
<br />sneer to death
<br />1 Year -
<br />onset
<br />19. WAS WED tsxAWNI R
<br />OR CORONER CONTACTED?
<br />(3 YES '`el NO
<br />21c. WAS AN AUTOP$T.P211 RM..ED?; ` ;::
<br />YE
<br />21d. WERE AUTOPSY FINDINGS AVA
<br />TO COMPLETE CAUSE OF DEAT
<br />❑ YES E NO
<br />22c. PLACE OF INJURY-Athoofu/ fenny street, factory, office building, construction Alta, SWAB
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22G LOCATION QF::(!i tURY. `:STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 29, 2024
<br />CITY/TOWN::
<br />23b. DATE:si13Nea,(Mo., Day, Yr.)
<br />'i:Oeceinbeit Si2024
<br />..
<br />23d To the: post kno•Meage, death occurred at the time, date and piece
<br />• to MO *weird stated. (Signature and Title)
<br />David Crockett, MD
<br />23c. TIME OF DEATH
<br />Unknown
<br />e° i
<br />6
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e.P
<br />OUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRO
<br />A CODE
<br />24i; On thit:.Wpie of examination and/or investigation, in my opinion death dccuttsd at
<br />' the time, dab and place and due to the cawa(sistated. (aigneture and TOO
<br />xli <;DID.:: 4QBIACCO IRE CONTRIBUTE TO THE DEATH?
<br />YES:"::. FRO ;:;''"';:Q:PROBABLY (3 UNKNOWN
<br />2 . NAME, T ..LND ADORES$ OF CERTIFIER (Type or Print
<br />David Crockett, MO, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN 0R:TISSUE 'DONATION
<br />;
<br />❑ YES ®NO`
<br />6 '2t A .'i c rv-n. rig
<br />EEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED
<br />Not Applicable if 26a Is NO,
<br />28b. DATE FILED BY REGISTRAR;{;
<br />December 9, 2024
<br />., Dar, Yr„)..,:,....
<br />
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