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.DECEDENT'S-i ME;; Orbit, iddle, Last, Suffix)
<br />Douglas Clarence ."'Bryant
<br />STATE OF NEBRASKA
<br />asco >:..<ngatt46i9511.P.PIlyc3s> �a8,•4�ih�a.,F,aa >«*<t9t499'fYPPIIDISF TtrAwpf.i,
<br />COP ARRIES THE RAISED SEAL OF STATE OF NEBRA:SKA,: IT CERTIFIES THE DOCUMENT BELOWT
<br />BE A.`TRUE CO'PY: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 />202601036
<br />SARAH BOHNEN
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HEAL
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH.,
<br />CITY AkD STATEDR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Polk, Nebraska
<br />t;soCIALSECURITYNOB.
<br />.
<br />896 46 4704
<br />FACILITY-NAME(If not In
<br />829...Redwood : td?
<br />Ic. CITY OR:T WN F:DEATH (btci
<br />Grla)Ind:)sland> 68803 ". .
<br />Re..RESIOENCE-STATE
<br />::::Nebraska
<br />ltta.
<br />1I FA'!'HE
<br />Clasen
<br />#Bryant:
<br />et and number)
<br />Code)
<br />lib. COUNTY
<br />Wall
<br />FIRE OF DEAc TH (g1 Married ❑ Never Manied
<br />d ❑ Widowed ❑ Divorced ❑ Unknown
<br />wRM D.. RCES?
<br />)Yes
<br />Last, Suffix)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83:. ;.
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Se. PLACE OF DEATH
<br />HOSPITAL L 13 ::InputUlnt
<br />❑ ER/Outpatient
<br />❑:'DOA :. .
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 14DAY
<br />NIINS.
<br />HOURS
<br />3. DA
<br />DOWN"'f r
<br />OTHER 0 Nursing Homa1LTC
<br />® Decedent's Home.
<br />❑ Other (Spey)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />ail.. APT: NO. ' at. LIP CODE
<br />68803
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give m
<br />Betty Davis
<br />12MOTHER'S-NAME (First, Middle, /Maideniun
<br />Eleanor:.:;Johnson
<br />14a. INFORMANT -NAME
<br />Betty Bryant
<br />19a. FUNERAL DIRECTOR SIGNATURE'.
<br />Kelley D Sheridan
<br />lib, LICENSE NO.
<br />: 1:439
<br />1sd(CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />#0FUNERAL HONE,NAME.AND MAILING ADDRESS (Street, City or Town, Sots)
<br />A : aliths;;Funeral )1ome, 2929 S. Locust Street, Grand Island, Nebraska
<br />/CAUSE OF DEATH'(See instructions and examples)
<br />Gibbon
<br />chats event- 4lses1es, injuries, or compilcstions4hat directly caused the death. DO NOT enter tarminai event such as cardiac arrest,
<br />without showing the etiology. DO NOT ABBREVIATE,. Enter only one cause on aline. Add additional lines x necessary.
<br />i;MMEDIATE CAUSE;:
<br />)C Irdi'o-Pulmonary Arrest
<br />Op EftLYdj!pi CAUSE
<br />irQury that tnhitd
<br />nauklnp in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Hypertensive Heart Disease
<br />TO, OR AS A CONSEQUENCE OF:
<br />OR AS A CONSEQUENCE OF:
<br />18 PART E.:ER SIGNIFICANT CONDITIONS -Conditions contributing to fhe death but net resulting in the underlying cause given in PART I.
<br />'Chronic Kidney Disease;, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease
<br />22r:. DA f F INJU
<br />20/-710
<br />n 42 drys of death
<br />47 days to.1 year before Oath
<br />c Pent Year
<br />(Mo-..Ri,Y, Yr.)
<br />21a. MANNER OF DEATH
<br />IE Natural ❑ Homicide
<br />0 Accident 0 Penangldvgtigatton
<br />❑ Suicide ❑ could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE
<br />RISE HOW INJURY OCCURRED
<br />OF.INJURY STRIEETS NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 24. 2025
<br />3b. DATE SIGNED (Mo,, day, Yr.) 23c. TIME OF DEATH
<br />tei s
<br />fix'��r 2 5 12:05 AM
<br />no.... ? the b et etink ,nowNdge, deathoccurred at the time, date and place
<br />»ad du►;to t . cause(s)Astated. (Signature and Title)
<br />Heather M'.:Fano, MD
<br />YES
<br />o PA.:.,...,:„„:..:„
<br />205S
<br />41... GNATURR I
<br />25a. HAS ORGAN 0
<br />❑ YES
<br />21b. IF TRANSPORTATION INJURY
<br />CI Ddv.r/Operator
<br />CI
<br />Poisoner
<br />❑ Pedesptn
<br />❑ Other (Specify)
<br />1.'
<br />21C. WAS
<br />D Yes
<br />21d. WERE
<br />TO CO)
<br />© YES
<br />iNJURY-At Fora e,:fartn, street, factory, office building,
<br />1ER (Type or Print
<br />coin Ave Ste 101, York, Nebraska,
<br />I
<br />t
<br />g
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />240 PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.
<br />2 d.
<br />24e:01 the be ge Or examination and/or investigation, in m
<br />d Miht
<br />thethe
<br />thus;•date and pica and due teaw cse(s) auded. (#ig1W)t1
<br />ssus common BON CONSIDERED?
<br />Ca No f
<br />21b. WAS CONSEN
<br />Not Applicable If 201i is
<br />\'
<br />21b. DATE FILED BY
<br />January 2, 2026
<br />25
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