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<br />,<. STATE OF NEBRASKA
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<br />MEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE 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
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<br />4.
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<br />OR.I$SBANCE
<br />5 4012024
<br />LINCOLN, NEBRASKA
<br />1. peceneNrs-NANIE (First. Middle, Last, Suffix)
<br />Cheater Dean Thornton
<br />• •:•• %.„,e4t4
<br />SARAH BOHNENICAMP
<br />ASSISTANT STATE REGISTRAR
<br />2 025.:01.-:70 DEPARTMENT OF HEALTH
<br />„„ •• • • AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4. diTONo:sTATE:oa:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Clarksdale, Missouri
<br />7. .SOCIAL SECURITTNUMI3ER
<br />488-444359
<br />86: FACILITY*AMEtIknot Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CEN.OR TOWN:40:DOTH (Include Zip Code)
<br />::'OrfltKri&faiKtS880.3
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />;4.4p Nossies
<br />10ii4140‘eiTAterATOsAT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated .ria Widowed 0 Divorced 0 Unknown
<br />AGE - LastBirthday 6b; UNDER 1 YEAR
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />PLAce
<br />aER/Outpattent
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />24 06669
<br />3. DATE OF DEATHOriolP.OV.,.7:9 :A!
<br />May lO 24,""
<br />s• DATE OF alkIIiiiita414iti..)
<br />July 27,1:940'
<br />)
<br />OTHER IR] Nursing Horne/LTC g:CliHotiplee Pactht
<br />o Decedenre Home "" .".
<br />0 Other (Specify)
<br />I 8d. COUNTY OF DEATH
<br />I Hall
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />MittgOltNalfl*
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give Mai
<br />Eileen Julie Christensen
<br />roe*
<br />./`
<br />•
<br />•
<br />11.FATHER'S-NAMEF1rst, Middle, Last, Suffix)
<br />Marvn:,Walker Thornton
<br />13. EVEBlid U 8 ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Uhk) No
<br />15. METHOD OF DISPOSITION
<br />LiO BMW • 0 Denison
<br />0 Cremation 0 Enterdbment
<br />0 Removal . Ottir (Specify)
<br />14a. INFORMANT -NAME
<br />Mike Thornton
<br />18a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />iTit. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />AdretFutleraftiode, 1123 W. 2nd, Grand Island, Nebraska
<br />12, MOTHER'S -NAME (First, Middle, Maiden Sums
<br />Katherine Darlene Filler
<br />18b. LICENSE NO.
<br />1448
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH ISiteinstructioliiiitid examples)
<br />It, PART I. Enter.' Michael of events..disessits, Injuries, or compiRations4hat directly caused the death. DO NOT enter tenninai events such as cardiac arrest,
<br />respirator/ arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional fines tf necessary.
<br />: IMMEDIATE CAUSE:
<br />irdKEDipt4PIKIE WOO a)Respiratory Failure
<br />Sequentially list conditions, If
<br />any, Reding to the canes fisted
<br />0011055•••• •••••• •••••••••'''• •••••:'
<br />• ''.•••• ••••••••••••• •••••••••
<br />ntsr
<br />: .•:•••.....
<br />.................... op**
<br />inkilitnat Inittrited
<br />•::
<br />14b. RELATi�ftSJiIpT�
<br />Sieniftcant ,,Other
<br />19c, DATE 011,, p,v..!.
<br />May 10.4024:gif
<br />• INA
<br />Nebraska
<br />APPROXIMATE INMRVAL
<br />.• , .
<br />ontlislVitIktitth
<br />< Wek,'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Aspiration pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />the *vents masking in death)
<br />LAST
<br />7 41,12/3.12*B: Plif201COR:21Or1CANT CONDMONS-Conditions contributing to the death:bid not ted6RIng in the 'underlying cause given In PART I.
<br />ahrOrde obetrUctiie 'Pulmonary disease, dementia, chronic alcohol abuse
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />< 1
<br />orr
<br />19. WAS 01100434400INEB:
<br />OR PORONEitCONTakOTED?
<br />OYES JN0
<br />20. IF FEMALE:.
<br />CFNot:errignirntprithirrEeerrt yssr
<br />. ;:. ... .:...:::••
<br />0....N.00.0.01,..buipoonint within 42 days of death
<br />E:1 Not pregnant, but prevent 43 days to 1 year baton death
<br />Unknown if the put year
<br />. .
<br />. . .
<br />220kOATE:.0F.INJURY,(MO. Day, Yr.)
<br />22d. INJURY AtWoittO
<br />OYES 0 NO
<br />21a. MANNER OF DEATH ::
<br />511 Natural 0 !loitod.
<br />El Accident 0 Pending indestiiiikM1:
<br />Suicide Could not be determlneq
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />\ I:I Miser/Operator
<br />Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPBy, PERPCID
<br />OYES 54ii0.1": '11:
<br />21d. weReAuT0Friiiiiiitasesi1ikLikike
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YE, ff* -
<br />22c. PLACE OF III.juRy+At otreet, factory, office building, construgBon aB*(9p
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />22k LOCATION OF INJURY STREET & NUMBER, APT NO cirtrrowN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 10, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mav 15, 2024
<br />23c. TIME OF DEATH
<br />03:50 PM
<br />0. tp,osootof:01.:knovillidge, duth occurred at the time, elate and place
<br />Ceilings) stated. ISIgnature and Title)
<br />Jennifer L. Brown, MD
<br />215. BIB7919AccO USE CONTRIBUTE TO THE DEATH?
<br />TES 0 NO. ti PROBABLY 0 UNKNOWN
<br />21
<br />HAMEOTtLE CE
<br />AND ,ApoRESS OF RTIFIER (Type or Print
<br />1
<br />9
<br />STATE
<br />24a: DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />•
<br />ODLj
<br />" " " " S'? •
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD._ ........
<br />:2411.01111le bale of examination andlorinvutlg.tloui, itt MY sPilllOR tifil0:Oe.Purrid.M
<br />*nets, date and place and due to ttie nauti(i) staled. (dianatUrSenillitiel •
<br />• • • •
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES El NO
<br />• ::•.::• :."
<br />•
<br />Jeitarter'L3roWn, MD, 729 North Custer Avenue, Grand 'Stand, Nebreska,.68863
<br />28a. REGISTRAR'S SIGNATURE
<br />ac-lez-46 4604/Lecikez4,--
<br />26b. WAS CONSENT GRANTED?::: :
<br />Not Applicable if 26a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 16, 2024
<br />ImAr
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