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<br />a �STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO'..
<br />BE A TRUE COPY fF 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 />I
<br />DATE pp ISSUANCE!
<br />1t23r22
<br />LINCOLN, NEBRASKA
<br />Z02600879
<br />I
<br />SARAH BOHNENKA
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1>'i EC TENTS NAME:(tWst Middle, Last, Suffix)
<br />Melvin ; Liee' >Miner ';.
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />McCook .Nebreska:
<br />X :;SOC IA# SECURITY NUMBER
<br />50t a3890
<br />Ea. AGE - Last Birthday
<br />(Yrs.)
<br />68.:::::
<br />lfir. FACILITY -NAME (if not Institution, give street and number)
<br />::Edgewood Vista .Grand Island
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 6880
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ad. STR ET AND NUMBER
<br />403t'Ed:na
<br />9b. COUNTY
<br />Hall
<br />be. MARITAL STATUS AT TIME`OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated 0 Widowed IX] Divorced ❑ Unknown
<br />11 FATHER'S NAME:: (First, Middle, Last, Suffix)
<br />,:Melvin ::lame:' Miner
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yea, No, or Unit) No
<br />15. METHODOF DISFOSITIUN
<br />0 Bunai 1/i) Donation' :..
<br />El Cremation Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Bb:UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c, UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ea. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA.
<br />i
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />.0,1V Sri,
<br />3. DATE'OF DEAT (Mo, Day. #r:) .>
<br />December 3 2025 '!`'
<br />S. DATE OF BIRTH (M0, D
<br />December 18,:1 q58
<br />OTHER 0 Nursing HomdLTO
<br />❑ Decedent's Home
<br />® Other (SI•cNywsSIS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ole. APT. NO.
<br />St. ZIP CODE
<br />68803
<br />t:1 No
<br />10b: NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />14a. INFORMANT -NAME
<br />Katelyn Holmes
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Benjamin Hall
<br />12 MOTHER'S -NAME (First, Middle, Malden Surname)
<br />teulah Belle Brown
<br />:16b. LICENSE NO.
<br />1305
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION .. CITY / TOWN
<br />Nebraska Anatomical Board Omaha
<br />17e . FUNERAL. HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Nebraska Anatomical Board,'986395 Nebraska Medical Center; Omaha, Nebraska
<br />CAUSE OF DEATH iSee Instructions and examples)
<br />1a. PART I. Enter the chain of events- diseases, injuries, or cemplicattons4hat directly mused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory meat, or ventricular RbriNation Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional line if necessary.
<br />IMMEDIATE CAUSE:
<br />e ieDIATEciiulrsiwii,.l;:; : „ )non -small -cell lung cancer
<br />*Haw ;crco WNlori::resuleng:
<br />In death)...,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />am, leading tothe muse listed::::.:
<br />an:lima,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />:.. Enter thiot#NDFALYIti:Q CAUSE
<br />(disuse or Mow that Initiated
<br />the event, resulting In death)
<br />LAST
<br />tL PARTII. OTHER :EIGNIFI
<br />Coronaryartery disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />NT CONDITIONS -Conditions contributing to the death::but not resulting in the underlying cause given In PART I,
<br />20. IFFEMAI E:
<br />.:Q Net pregnant.wldMlpest:year >
<br />Pngiisnf tit time Of:deat :�I
<br />':0 Not pregnant, bill pregnant'wnhIn 42 days of death
<br />0 Not pregnant, but pregnant 43 days tot year before death
<br />Ctivnimow..:#.44.nontividasthir.past yar
<br />DATE OF INJURX (NM , Day Yr.)
<br />22d. INJURY AT WORK?
<br />DYES ONO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hofliidde • . .
<br />D. Accident ❑ Psnt8n9:A.nvelfgation'. ..
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />.:.O Passenger
<br />❑ Pedestrian
<br />❑ Other (Spelcify)
<br />14b. RELATIONSIEP 1'O C
<br />Daughter,
<br />18c. BATE (atri;; C).tty, tYo
<br />December 3,15
<br />17ti Zip Cods ;..
<br />68'1+9 95
<br />orie.ttoigljji''
<br />19' WAS Mestc4L E'.1CACAIN
<br />OR COMONge CONTACTS
<br />❑ YEe
<br />24, WERE AU
<br />TO COM
<br />❑ YES
<br />22c. PLACE'OF INJURY-Athomet:farnt street, factory, office building,
<br />DESCRIBE HOW INJURY OCCURRED
<br />O INdtllt r, STREET fA NUMBER, APT.NO. CITY/TOWN
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />December 3, 2025
<br />23b.: DATE:siotI D (Mo., Day, Yr.)
<br />l ecembe€:3 t?25
<br />23c. TIME OF DEATH
<br />03:00 AM
<br />xid. fb tht.bNit Of:nw Iffiffitkidge, death occwtied at the time, date and place
<br />dutitoth.ceiise(a) stated. (Signature and 'rule)
<br />Gary L Settle, MD
<br />2ti:"DID TOBACCO; USE CONTRIBUTE TO THE DEATH?
<br />:: ;YES ffi0 NO ;'❑;PROBABLY 0 UNKNOWN
<br />V. NAk
<br />Gar
<br />lo-
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)N.
<br />24c_ PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME
<br />tSe.On the basis of exambrtion and/or kwesegatbA In my
<br />the tMN, date and place and due to the mum(s) stated
<br />26a. HAS ORGAN ORTISSUE.DONATION BEEN CONSIDERED?
<br />❑YES j No:
<br />ADDRESS OF CERTIFIER (Type or Print
<br />MD, 416 N Deers Ave, Grand Island, Nebraska, 68803
<br />I
<br />26b. WAS CONSF OW*
<br />Not Applicable If 284 Is NO
<br />28b. DATE FILED
<br />December
<br />
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