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STATE OF NEBRASKA
<br />WHEN THIS COPY PARRIES 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
<br />.E
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<br />LYATE OFISSUAoICE'>
<br />3/6/2025
<br />LINCOLN, NEBRASKA
<br />17DEeEDENTS-NAME {First;;: Middle, Last, Suffix)
<br />Howard Daniel Hassett
<br />2025(J 912
<br />� 4-/Lien4
<br />SARAH BOHNENKAMP1
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICAT.:: OFQEATH
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Delano,;Calrfornia
<br />7. SOCIAL SECURITY NUMBER /
<br />507 80-0795
<br />5a. AGE Last Birthday
<br />(Yrs )
<br />8b. FACILITY -NAME (If -riot Institution, give street and number)
<br />Graz d'island Lake.Yiew Care & Rehabilitation Center
<br />so. CITY OR TOWN OF•CEATH (Include Zip Code)
<br />Grand Island 68801'
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />4 STREEI':ANp NUMBEk:::.
<br />1703 S. Arthur Sr,
<br />9b.000NTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH Ea Married ❑ Never Married
<br />❑ Married, but sepai•ated 0 Widowed 0 Divorced 0 Unknown
<br />14:FATHERRS7NAME wino, ':' Middle, Last, Suffix)
<br />JOseph 'Hassett
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />is. METHOD OF;OisFpa)T)QN
<br />❑;:Burial ❑ Donation<,
<br />Cremation:O Entombment
<br />❑ Removal 0 Other (Specify)
<br />68
<br />5b7UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />.+2.5: 2759:::
<br />3. DATE OF DEATH lMa:; Da
<br />February 16,.2025
<br />6. DATE OF BIRTH(Mo., Day, Yr.)
<br />May 17, 1956
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />/0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />I..
<br />9f. ZIP CODE
<br />68803
<br />❑ WM*, Facility
<br />9y)::INstme CITY LIMITS
<br />t';YES [].::I
<br />10b. NAME OF SPOUSE (First, Middle, I,.ait, Suffix) If wife, give maiden name
<br />DeAnn Chase..:
<br />14a. INFORMANT -NAME
<br />DeAnn Hassett
<br />16e. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First,
<br />Beulah Kaiser
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) N'
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island; Nebraska for -
<br />Othgr (Scecifv), .
<br />lib. LICENSE NO.
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events suchaycardiac arrest,
<br />respiratory crest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />I.fdM60IATE CAua iftnai > :a) Myelodysplastic Syndrome
<br />disease of condalon resulting :"
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />,fly, Ladling in the *ease Hated f?
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE' C)
<br />(di or Injury that initiated
<br />the events resulting in death)
<br />LAST ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART I1 OTHERSIGNIFIcANT CONDITIONS -Conditions contributing tf: the death but not resulting In the;udderlying cause given in PART I.
<br />congestive heart failure, type 2 diabetes mellitus, hypertension, peripheral vascular disease
<br />20,. IF FEMAtiE:::
<br />❑ Not regna pnt wit in past year:;,;
<br />.❑ Fregen nosSt tine nt death
<br />Not pregnant, put pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown It pregnant wittiin:ttte past year
<br />22a. DATE OF INJURY {MO.; ), Yr.)
<br />22d. INJURY AT WORK?
<br />YES::. ❑NO
<br />22f. LQCATI
<br />14b. RELATIONSHIP TO D
<br />Sp()Use
<br />16c. DATE (Mo, Dayr:.')
<br />February 19;:,2d25
<br />ECEDENT
<br />STATE
<br />4ebraska
<br />17b.Zip Cade
<br />68801'
<br />'APPROXIMATE INTERVAL
<br />onset to t3+fllt
<br />5 Months . ':<:
<br />onset to death:'
<br />19. WAS MEDICALEXAMINER .>' .
<br />OR CORONER CONTACTED?
<br />❑ YES E.NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homickta
<br />O Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME -OF INJURY
<br />21b;.iF TRANSPORTATION INJURY
<br />:•0 Driver)Operator
<br />: ❑ Padsenger
<br />❑ Pedestrian /
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPS'f PERFORMED?
<br />❑ YES ® N
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ N(Dj:..:
<br />22c. PLACE OF INJURY -At homa;::fann street, factory, office building, construction sit. ate. (Spa;tify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY:::STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 16, 2025
<br />CITY/TOWN
<br />23b DATE SIGNED:(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Fpl ryiaiv 17 2025 08:30 PM
<br />3d. To thrl bestctitny knowledge, deathoccurred at the time, date and place
<br />`tnd tkdi to terceuse(si stated. (Signature and Title)
<br />Chad Vieth, MD
<br />I.
<br />g
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yy.)�
<br />24c.'PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2Af1 CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED ©FAD
<br />241,1, On the:beeis of examination and/or Investigation, In my opinion death occurred 4t
<br />,the time, date and place and due to the cause(*) stated. (Signature and line)
<br />26a. HAS ORGAN OR:TISSl3EDONATION BEEN CONSIDERED?
<br />❑ YES Ig] NO
<br />2�:DID.TOBACC(t USE CONTRIBUTE TO THE DEATH?
<br />0. YES ❑ No 0:PROBABLY ® UNKNOWN
<br />27. NAME, TITLE' ANt) ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a REGISTRAR'S SIGNATURE L, 0-4et../'g
<br />/ .64/Le- 1 r
<br />26b. WAS CONSENT ORA
<br />Not Applicable if 26s is NO
<br />28b. DATE FILED BY REGIS
<br />March 3, 2025
<br />Qg1f Yr 3
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