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<br />STATE OF NEBRASKA
<br />°, . :+tEiirllt.'1'I1'PIIDSps .o.%G44'IAp'.Sa`
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<br />VtlHEN HI OPY CARRI, S: THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />BE A TRUE,:CoPYOF 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 />DATE t l$ t►ANCE::: ;€
<br />11'23/2026
<br />LINCOLN, NEBRASKA
<br />20260'080.4
<br />SARAH BOHNENIAMP
<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 />t ENT S-NAME (Ftr.t, ; Middle, Last, Suffix)
<br />eph >; Rict i . ;;Stepanek
<br />4.CrrY ANDSTATE OR TERRITORY, OR FOREIGN, COUNTRY OF BIRTH
<br />:St: P.auL Nebraska::....
<br />7,:SOG4AL SEGURITff:Nlkj BER;
<br />:.:. 50b"922*7264' :: <:>'
<br />5b. FACILITY -NAME (If note stitutlon, give street and number)
<br />CHI hltaith St; Francis.
<br />CITY OR TOWN ¢F 0004. (Include Zip Code)
<br />Grand::lsland'»68803 <:'
<br />9a RESIDENCE -STATE
<br />,Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d::STREET'AND NUMBER ''' :..
<br />Itlit MARITAL STATUS AT"TIME OF DEATH l] Married ❑ Never Married
<br />❑ Married, but *spiraled ❑ Widowed ❑ Divorced ❑ Unknown
<br />11 FATHER'S NA6...f4> iFl rt<'.`: ' :Midrib Last, Suffix)
<br />/
<br />Stepanek
<br />k EVERlt�4
<br />(Yu, No,
<br />S. ARMED FORCES?'
<br />Unk.) No
<br />1l1, METN0DoF,DI8POSITION:
<br />'d Cr .tlon' ❑ F.nti rrir?Iraprit
<br />❑ Removal0 Oth r iSpdcity)
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />5bi UNDE21 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOB.
<br />DAYS
<br />8a. PLACE CIF,DEATH:::
<br />HOSPITAL V inpatient:
<br />0 ER/Outpatient
<br />❑ DOA..:'
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo;:
<br />January 2, 2026
<br />8. DATE OF BIRTH Mo..
<br />March 13,1655:
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (SpscIfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a: APT. NO.
<br />et. ZIP CODE
<br />68803
<br />10b.\\NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mahyen nim.
<br />May Ann Smith
<br />12. MOTHERS,NAME (First, Middle, Malden Sumams)
<br />Rita : Knapik
<br />14a. INFORMANT -NAME
<br />Mary Ann Stepanek
<br />16.. FUNERAL DIRECTOR S GNATURE
<br />Stacie L Cook
<br />18d. CEMETERY, CREMATORY OR OTHERLOCATION•.:`
<br />Westlawn Cemetery
<br />17a1. FUNERAL<HOME NAME'AND MAIUNG'ADDRESS (Street, City or Town, State)
<br />All Faith 'Funeral Home. 2929 S. Locust Street, Grand Island :Nebraska
<br />16b.. LICENSE NO.
<br />1498
<br />/ CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1R PART I. Eniert s chain of events- eitite , injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arm*, or ventneulerl9ntllaton Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />I Di ; a ue iif ►i ;! ' *Myocardial infarction
<br />In death). "" '"' f DUE TO, OR AS A CONSEQUENCE OF:
<br />SetwerithrilyHet ondlltomr,N b)
<br />M A o•adlog tetM nisi
<br />*IIIie
<br />lE TO, ORASA CONSEQUENCE OF:
<br />ury that
<br />the events resugmg in death) DUE
<br />Ewer .... d)
<br />ki,ART`.11 07 ertSigell i
<br />"' Diabetee'tnslfttUit',
<br />28..;IF FEMALES..
<br />Nae K*ftasiit addsia'.E
<br />` Q Pr gnsra.tdma of4efffi: i;.,
<br />pr.gnaM, but pregtaipf`wi hin 42'days death
<br />Regnant, but Pregnant 43 days tot year before death
<br />own If:pregnant with/ 11. pea year
<br />OR AS A CONSEQUENCE OF:
<br />ITIONS-Conditions contributing to the death but not reciting* tliSundsrIying cause given In PART I.
<br />INzIuR:r (lei=€ Qsji Yr:),
<br />)2d. INJURY AT WORK?
<br />21a. MANNER OF DEATH :>
<br />® Natural ❑ How**
<br />❑ Accident 0 Pending tnvatipetion
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE'CIP:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22?. LOC 11ON ')F I JURY . STREET , NUMBER, APT.NO. I CITY/TOWN.
<br />DATE OF DEATH (Me., Day, Yr.)
<br />January 2, 2026
<br />,.. DATE ;SIGNED :.(yto., Day, Yr.1
<br />January 1:5 2026
<br />23c. TIME OF DEATH
<br />11:42 PM
<br />tea tiatoftEiy eIefladge, death occurred et the time, date and place
<br />N diiu ty-the:14.1•i(a) seed. (Signature end Title)
<br />Jeffrey King, MD
<br />N.S Vitt IF:TRAPORTATION INJURY
<br />Drier/Operate�.
<br />❑ Paaangtr
<br />❑ Pedestrian
<br />❑ Other(Specxy)
<br />1111' s I ,.
<br />cI
<br />14b. RELAT►ONSHIP TO DECEDENT
<br />Spouse ..:
<br />18o DATE(MO,fhry,YO
<br />17b.T,tp'Ce+d
<br />6$t141<_
<br />19. WAS M )C 7CA M1lIt R;:r
<br />OR CDROMER Ci€ NTACTED?
<br />❑ YES`
<br />21c. WAS AN AUTOPSY PERFORMSE?
<br />❑ YES
<br />21d. WERE AUTOPSY FI0INOSAVAtL*SLti'
<br />TO COMPLETE. CAUSE OF DEATH?
<br />❑ YES $O ...•
<br />Y:At.horrid:.ramt:streef;'factory, office building, const
<br />STATE /
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRO
<br />n
<br />24b. TIME OF DEA
<br />( i•ciry)'
<br />PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PROI4 UNCEp DEi
<br />beltct examination and/or Investigation, In my'opinloe dense, eeeureif at
<br />ie, date end glace and due to the causes) stated.
<br />t IUM AG(30'USE GONT IBUTE 26a. HAS ORGAN:' OR, TISSUE DONATION: BEEN N,CONSIDERED?
<br />... ';iJ&I I'Ir : 'z'.>:❑...:.>. ❑ YES : .... No
<br />16EE TIi1E: AND ADGRASS OF CERTIFIER (Type or Print
<br />ffreyK1` MD,'3815 Richmond Circle, Grand Island, Nebraska, 68803
<br />YES.
<br />TO THE DEATH?
<br />PRO ❑ UNKNOWN
<br />26b. WAS CONSENT
<br />Not Applicable If 28a Is NO
<br />28b. DATE FILED BY REGISTI
<br />January 16, 2026
<br />ay, Y►.) .`.
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