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<br />STATE OF NEBRASKA
<br />24ri�i INE!N <:QVII:CII,(11VDt>�.
<br />COPY CARRIES THE RAISED ; EAL` F ;::'SHE: ':`STATE OF NEBRASKA,
<br />>s ;CERTIFIES :;;THE DOCUMENT BELOW TO BE' : A <TSI E' :;COPY OF THE ORIGINAL RECC
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, V►TAL
<br />RECDR138:OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.:VITAL. RECORDS
<br />: '..; : ';` STANLEY S. OOPER
<br />(�
<br />2 W 2 ': ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT:OF'HEA4TH:AND HUMAN SERVICES
<br />CERTIFICATE,OFDEATH'
<br />0/2016
<br />Al NEBRASKA
<br />i. DECEbENTS-NAME (PI
<br />Russell LeRoy I
<br />Last, Suffix)
<br />LiT'Fi ANOST.ATE 0R:;T.. R.RtTORY: OR FOREIGN COUNTRY OF BIRTH
<br />It. Petit Neese
<br />7. SOCIAL SECURITY NUMBER
<br />_..50542-707.1.
<br />tiff: FAcitri`v-ttAat s Of not lnostos
<br />Olt Health;:St. FranCis
<br />vs street and number)
<br />mac. CITY OR SOWN OF DEATH (Include Zip Cede)
<br />Grand Island 68803'
<br />9A; RESIDENCE STATE:
<br />.Nraslta:;>„ :<
<br />STREET AND NUMBER
<br />4016 Kay Ave
<br />Ob. COUNTY
<br />Hall
<br />att. MARITAL ;Tani S..AT TIME OF DEATH ® Married 0 Never Married
<br />�own artled, but sltpprateil:_ 0.W)dowed 0 Divorced ❑ Unknown
<br />n
<br />i, PATH;ER'S-NAME (First, Middle. Last, Suffix)
<br />Henry Harvey
<br />1.3 EVERIN U.S..ARMED,FORCES? Give dates of service if yes.
<br />1Y s N or Sink ).Yes'' `:11 /07/ 955-06/21 /1971
<br />6 METHOD zOF`D SPOS►TIOift
<br />® Buda! f3onaflon
<br />Q Cr►mation 0 Entombment
<br />Ci Ftfinicwai ::«:El Other (EP60ifYi
<br />17��iNE
<br />Alt' Fl
<br />tell. AGE'-:t.aetBIrtltdaY;
<br />UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />Mtss
<br />sa. PLACE OF DEATH
<br />OSPITAL ® inpatient
<br />:::0 ERlOtitptltlent
<br />"i..,t: DOA::.:':,.,.
<br />YS
<br />9c. ct
<br />OR TOWNnd !eland
<br />HOURS
<br />MINS.
<br />3. DATE OF
<br />June 20, 201
<br />OTHER 0 Nursing HomsILTC
<br />❑ Decedent% Home
<br />❑ Other (SpecIfy)
<br />ad. COUNTY OF DEATH
<br />Hall
<br />VG. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lOb. NAME OF... SPOUSE (Fink, Millie, Last, Suffix) If wife, give maiden n4dlfb.
<br />Janet.. heresa:.TOpel
<br />12. M niaira NAME (First, Middle, Malden Suntams)
<br />Alta Klein
<br />14a. INFORMANT -NAME
<br />Janet .Theresa "Harvey
<br />164. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />eb;. LICENSE NO.
<br />1454
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Grand Island CityemeteiY : ::: Grand Island
<br />HOME >NAME 'AND MAILING ADDRESS (Street, City or Town, State):'
<br />Funeral_ Home, 2929 S. Locust Street. Grand island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />.,tRT Enka t1q.dhs)tt af5••• $- disause, lurks, or complications -that directly caused tM;Matir, D° JOT enter emtinarewirds such** cardiac arrest,
<br />:rfspiratofy arras% at vantr#cul*r fibrillation without showing the etiology. DO NOT ABHflEVIATE. Enter only en. cause dna link Add additional tines B neceafary.
<br />:'. IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE -trim' a) Aspiration Pneumonia With Sepsis
<br />dlang. ar con% itlon resulting
<br />death),,,,
<br />Sequentially I.tftt
<br />any tsadln?tottis�causelistri
<br />Enter the UNDERLYING CAUSE
<br />,.;(dkrsa.or...INury t.M.t roltlatssd .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Dysphagia With Aspiration
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />O) Severe Alzheimers Dementia
<br />TO, OR AS A CONSEQUENCE OF:
<br />Yt).
<br />14b. RELATKR*IP TO DECEDENT
<br />Wife
<br />168. DATE (M44DayyW1"4::::
<br />June 244201'6
<br />STATE.
<br />t.:rf Onset eattt-.
<br />About4060th
<br />MOW1b death'
<br />» About 5 Years
<br />79, PART II. OTHER SIGNIFICANT CONDITIONS-Condkions contributlng to the death but not resulting In the underlying cause given In P
<br />Type II Diabetes, Hypertension, Hyperiipidernia
<br />►usr:pt*A hee'wshfn; Sly ar
<br />a Pohlman interne of death
<br />;:.. Not pregnant, but pregnantwithin 42 days of death
<br />........
<br />ot pr j).nanK tit¢ pTsing t:Aa days tot year before death
<br />Unlcnawn i(p;ifgnlaat:witl!In;iM,paa year
<br />IN'JURY'(MO. Day, Yr.)
<br />JURY ATWOftK?. ,.:,
<br />Y .... <<...<'• :
<br />CA'ftON0F If
<br />21a. MANNER OF;DEAI•.
<br />El Natural Homicide
<br />❑ Accident El Pending Investigation
<br />❑ suicide ❑ Could not be d ftennined ..
<br />22b. TIME OF INJURY
<br />.21b. •WTRANSPORTATION INJURY
<br />(lrirar/Op!rator
<br />❑ Passenger
<br />El Pedestrian
<br />of!ter, (%Psci►Y)
<br />22c. PtA10E`OF INJURY At Mine, law,
<br />E HOW INJURY OCCURRED
<br />URY : STREETS NUMBER, APT.NO.
<br />CITYITOWN
<br />lac
<br />ART I. 19. WAS MEO(CAkl. fc%AMk
<br />OR CORONER� CONTAC
<br />YES
<br />21c. WAS 8.0.E.RFOBM
<br />❑ YES >>_
<br />21d. WERE AUTOSS9Y ilt4C41408 AVAI(ASte
<br />TO COMPLETE. CAUS '::Q! DEATH?
<br />YE oei >"
<br />, office bulking,
<br />STATE
<br />ma. DATE OF DEATH (Mo., Day, Yr.)
<br />Jane 20, 2016
<br />:23D. DATE'SiG.NED (Mo., Day, Yr.)
<br />J04 44316
<br />Steyen Husen, MD
<br />23c. TIME OF DEATH
<br />10:19 AM
<br />urred at the time, date end place
<br />we and Tait)
<br />TO THE DEATH?
<br />26a. HAS 0
<br />❑ YES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Mc.
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />24d. TIME
<br />24e. On the basis of euminetbn andlor Investigation. In my
<br />the time, date and place and due to the causela) stated. (
<br />OR TISSUE NM1
<br />CI PROBABLY 0 UNKNOWN
<br />NAME,'11Tii alb ADDRESS OF CERTIFIER (Type or Print
<br />ven HuSen, MD, 2116 W Faidley #1400, Box 9802, Grand Island, Nebraska, 68803
<br />R
<br />:: BEEN.CONSIDERED?
<br />26b. WAS CONSENT 0
<br />Not Applicable If 25a Is NO
<br />2Sb. DATE FILED BY
<br />June 27, 2016
<br />:E0 DEARD
<br />
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