|
STATE OF NEBRASKA
<br />i<y.h90d.S5ec.'.:.. «.yygtll'11,'YfItIDJsc.":: '+92.riTt'PIIDSot,''; : a7,y41'I'lal'tttlDJ�t,'.,.,..:: roWit dJt!
<br />igYi i+ II', HIS COP :ARR1E'S;THERAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />B .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 />ATEEOR'TE*RITO),V
<br />I r 144140iUetrr t o
<br />3b. nFACILITY-NAlittlit notIfgatitution, gives
<br />CHC Iivalttt 3 1A"441 43 , .
<br />:ilb CITY OR TQ I:i t? DMAt I Inglttd
<br />t3rand•:)S)and "8S# / .. '.
<br />Far REESIDENOtt-STATE
<br />`''Nebrsa)¢'8
<br />st 1REE`'A D NU{MSER
<br />toa. MARI A). STATUS AT TINE I
<br />.� Marrfed,;butteparuted
<br />Y 1 fATHER'.S NAM
<br />iUtf itoWn;it pale.
<br />22a, QltTE <i) >INxt $
<br />22d. INJURY, AT WO
<br />2aa; DATE OF DEAY)
<br />May 27, 2025',
<br />2510.,IiiTE41011IP4kM
<br />202503327
<br />74,,A 0/344.1/240
<br />SARAH BOHNENKA.MP
<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 />Last, Suffix)
<br />REIGN COUNTRY OF BIRTH
<br />et and number)
<br />Zip Code)
<br />8b. COUNTY
<br />Hall
<br />F DEATH El Married 0 Never Married
<br />Wk$owed ❑ Divorced 0 Unknown
<br />Idd(M, Lilt, Suffix)
<br />vedates of service if Yea.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />Be. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />-:SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />3. DATE C
<br />May 2
<br />OTHER 0 Nursing Home/LTC,
<br />0 Decedent's Home
<br />0 Other (Specify) \
<br />8d. COUNTY OF DEATH
<br />Be. APT. NO. \
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife
<br />Sharon Kay Vilas
<br />14a. INFORMANT -NAME
<br />Sharon Kay Neid
<br />BALMER-SIGNATURE
<br />Not Embalmed
<br />ied. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ADDRESS (Street, City or Town, State)
<br />12, MOTHER'S -NAME (First, Middle, Malden Surttaiite
<br />Gertrude Baker
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examDlesl
<br />atns, ures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac west,
<br />Maim without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />(HATE CAUSE:
<br />static bladder cancer
<br />TO, OR AS A CONSEQUENCE OF:
<br />A CONSEQUENCE OF:
<br />AS A CONSEQUENCE OF:
<br />NDITIONS-Conditions contributing to the death but not resulting in the u
<br />ath
<br />ore death
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />erlying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />0 DoverOperator
<br />Paaaenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. Ri'S) A9
<br />SP9.*
<br />1sc. DAte
<br />May'2l
<br />21c. WAS ANAUTO
<br />❑ YES
<br />21d. WERE AUT'OPAYFINDI
<br />TO COMPLETE,QAU5!
<br />0 YES
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construct
<br />IBE HOW INJURY OCCURRED
<br />b NUMBER, APT.NO.
<br />Day, Yr.)
<br />y, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />01:00 PM
<br />each occurred at the time, date and place
<br />,.(Signature and Title)
<br />I. <10.0.00CON'1RtEt♦z TKO TNa DEATH?
<br />ES:::.• AIBLY UNKNOWN
<br />27. ffmig, T(7LE:ANDMODRU O1 CIaRTA I R (Type or Print
<br />TOM AS S;, Hag�9eman, MD, 720 North Custer Avenue, Grand Island, Nebraska, 68803
<br />ECiISTRAR!s SIGNATURE 1 _
<br />$a
<br />v
<br />STATE
<br />24*. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.),
<br />24b. TIME
<br />24d."TIME'
<br />Ike. On the basis of examination and/or investige ion, In my,oietil ni
<br />the time, date and place and due to the causal.) stated Plible tuw
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES to NO
<br />26b. WAS CON
<br />Not Applicable If
<br />26b. DATE FILED BYRE
<br />May 30, 2025
<br />•
<br />S
<br />A'ti4
<br />
|