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<,..utWedap>irrv��ts'd��43�1�iYAWa�i�a�a
<br />�,/tea4)n STATE OF NEBRASKA
<br />t�2'11r1111�Nrr1r�K" hN£k%Iii.I.I.AIrfiiilr85e. .:I�tI ......... s,§kefi I ...._..._....... .....% ................
<br />WHEN THIS CO Y'CARRIES THE RAISED SEAL OF STATE OF NEBftASKA,>IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />• HUMAN SERVICES; `VI.TAL RECORDS OFFICE, WHICH IS THELEGALDEPOSITORY FOR VITAL RECORDS
<br />*15
<br />" DATE OPISSUAII[CE
<br />`9/1>2O23
<br />LINCOLN, NEBRASKA
<br />I., DECEOEN15NAME,'(First, Middle, Last, Suffix)
<br />Stuart :Lynn:` SOdorf
<br />202503707
<br />SARAH BOHNENHA
<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 />4. OITYiAND STATE TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Franklin,'.Nebraska
<br />7.;:SOCIAL SECURITY 'NUM BER
<br />505-70-7616<
<br />66. F40iLrrY44Aist (#f not Institution, give street and number)
<br />Bryan Medical Center West
<br />Sc. t rTY`QR OWO:dt
<br />Lincoln
<br />la. RESIDENCE -STATE
<br />Nebraska
<br />Sd.;STREET ANS NUMBER
<br />1912 ill :Charles St"
<br />TN (Include Zip Code)
<br />lb. COUNTY
<br />Hall
<br />ime:mARITA .STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11.;F47:!.1:011r1104ME:.;(Flsst, Middle, Last, Suffix)
<br />Reuben::::>Endorf::
<br />13:::EVERt 1N 0.*A0.400 FORCES? Give dates of service B Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />J Burial Donation
<br />0 Cr en st of C]yEntombment
<br />itaidovsi 0 Other (Specify)
<br />5a; AGE - obit 9frthd*j j
<br />(Yrs.)
<br />68:..
<br />lb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2312222
<br />3. DATE OF DEA r(4Mo.:Ginn :)
<br />September i, 20 :..
<br />6. DATE OF
<br />March 20 s1955,
<br />Sa: PLACE OP::DEATH;: .
<br />® I HOSPITAL;:npatient OTHER 0 Nursing Home/LTC
<br />.-.• • ❑ ER/Outpatient 0 Decedent's Home ,
<br />❑ OOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Other (Specify)
<br />Ilid. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />M. ZIP CODE
<br />68803
<br />VA. NAME OF SPOUSE (First, Middle, Last, Suffix) if
<br />Barbara Lute
<br />14a. INFORMANT.NAME
<br />Barbara Endorf
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MDTHER'S.NAME (First, Middle, Maiden
<br />Norma: Mason
<br />18b. LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION .. CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERALpDHERAL:HOME_NAME AND MAILING ADDRESS (Street, City or Town,,State)::
<br />All F&iiths;;:Fuleral'Home, 2929 S. Locust Street, Grand Island, Nebraska;: ;;,
<br />CAUSE OF DEATH (S
<br />InStructloris and examples)
<br />ie. PART I. Enter the chain of events- ttlseases, Injuries, or complications hat directly caused the death. DO NOT inter terminal *vents such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Me. Add additional lines if necessary.
<br />, IMMEDIATE CAUSE:
<br />I M ix TE CAUSE Pine <j>>' a) Sepsis
<br />dl aase or condition muting<
<br />In
<br />Sequentially list conditions, If
<br />. any, tooling to Ow Cartel.listed
<br />Enter.th INDERLYiNf80/80.3
<br />Idirfus or irduiythat IiiTtlated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART IL:Ci E'SIGNIFICANT CONDITIONS -Conditions contributing to the death- .biR ndt:resultinp'in'thAUnderlying cause given In PART I.
<br />Coronary Artery Disease, Hypertension, Deep Vein Thrombosis, Pulmonary Embolism; Vtelden Disorder
<br />29. IF..FEMALE:.,.
<br />[ ,.:Nrot p egnant ritFK n pest'year
<br />CIEJ,reillilltitoe:trtie.44•44t
<br />Not pregniirt;::but pr Ogrient within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />C'l..Unknown Fjxegnrntwithin the past year
<br />22a:: DATE:OF::INJUI
<br />22d. INJURY AT WORK?
<br />❑ YES .L] NO....
<br />ISc LOCATion
<br />5
<br />y, Yr)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Rootlet/Is
<br />Accident("sj':Pending l lyeltigagpn
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />It41U1tY':.. STREET S NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 1, 2023
<br />F INURE
<br />21b.. IF TRANSPORTATION INJURY
<br />:. Dr/wr/Operator
<br />Paisengsr
<br />❑•Pedestrian
<br />❑ Other (15pectfy)
<br />`�:I•� 1M�DEt'irIY4:1M1'f$ ;
<br />I YE6'i. J''rNO
<br />14b. REI.ATI
<br />Spouse
<br />P TalieraEt3ENT
<br />18c. RATE Dit0, Say,,Yr,1;
<br />SeOtembetL*> 17
<br />APPROXIMATEI
<br />"BETAath
<br />24 Hours
<br />Onset to death
<br />onset to deaiti
<br />19. WAS Msr:1 L
<br />OR COtRCi
<br />® YES
<br />210. WAS AN AUTOPSY PE
<br />❑ YES 11,140
<br />21d. WERE AUTOPSY'FI NDINGS AVAtLABtE
<br />To COMPLETrE�CAUSE OF DEATH?
<br />0 YES •
<br />:me farm, street, factory, office building, construction site,
<br />art NM' STATE
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />fteetember.11. 2023 06:15 AM
<br />TO th. blit;of m2knowledge, death occurred at the -tens, date and place
<br />ettddue to:the Cuuss(s) stated. (signature and Title)
<br />Michael L McCann, DO
<br />25. DIO:TOBACC.O USE CONTRIBUTE TO THE DEATH?
<br />YEs NO::. "�r^�' PROBABLY 0 UNKNOWN
<br />27 ; ME, TIT ,E AND ADDRESS OF CERTIFIER (Type or Print
<br />Ai ICA'Sd LIAcCann, DO, 2300 S 16th Street, Lincoln, Nebraska, 68602
<br />28a. REGISTRAR'S SIGNATURE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr,)
<br />24d. 'TIME PRONOUNCED DEAD,::
<br />'the basis of examination and/or Investigation, In my art a. .
<br />s tints, date and place and due to the cause(*) statad, ($lgnetuni .This)
<br />26a. HAS ORGAN ORORGAN OR ?ISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i INO
<br />29b. WAS CONSENT GRAN':i;SG''
<br />Not ApplIcabie if 26a is NO
<br />:NO
<br />is
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 11, 2023 •.::::: ;..:.. j:.?:. ':::
<br />
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