|
r/
<br />.:�. �Ftlrrr'lll/�/%y i�P.4,,C; ;t��lii� ��l�� •ir,na?¢�t ((1 ))),��� e��,f��✓.re�n.���w��u,�r�Fin,,,�" ��111r1rlfll/�i�F'
<br />I%t.Ni INus " !frhlll'I:IflrthSs�
<br />r245h4ih'J5.>
<br />f 1111taflIRO s!atve ms
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE 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 />DATE OF ISSUANCE
<br />3/11 /2026
<br />LINCOLN.NEBRASKA
<br />-202601875
<br />SARAH BOHNENKAMP
<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 />1.OEDENT`$4tAME (Fist, Middle, Last, Suffix)
<br />Gloria RUthalee Gallion
<br />2. SEX
<br />Female
<br />1801301
<br />s. DATE OP°� T4.40so., t
<br />March 5, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />•
<br />illedo, Illinois
<br />7. SOCIAL RCURITY'NUMSER
<br />508-52.0468
<br />6a. AGE • Last Birthday
<br />(Yrs.)
<br />76
<br />lib. FACILITY -NAME (If not Institution, give street and number)
<br />Park Plac,9 1 GOldan Living Center
<br />tic. 11Y ORT N OFDDEATII (Mciu(e ip Code)
<br />Grand Island 68803
<br />Se. RESIDENCE -STATE
<br />Nebraska ..
<br />lid. STREEYAND NUMBER'"::
<br />1410 Vit Division Street
<br />lib. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH to Married ❑ Never Married
<br />aMilf led, bu. t separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11.FATHER'S-NAME (Mat,Middle, Last, Suffix)
<br />Perry Raymond "Grigsby
<br />1S. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yee, No, or Unit.) No
<br />tti kiiin is OF,DISPOSfTJON
<br />❑ Burial ❑DonatIon
<br />" Itfernettation?©Ennton 6ment
<br />❑ Removal ❑ Ot er (Specify)
<br />6b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />an,. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />S. DATE OF
<br />Feb
<br />OTHER RI Nursing HoneILTC
<br />❑ Decedent's Hone
<br />- 0 Other (Specify)
<br />tide COUNTY OF DEATH
<br />Hall
<br />Ile. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Day, Yr.)
<br />-,r
<br />PEE
<br />ip. )NSOOOOOO R.(«trTa
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />David Gallion
<br />14a. INFORMANT -NAME
<br />David Gallion
<br />lea. EMBALIYiER-SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Martha Ruth Eaton
<br />16d. CEMETERY, CREMATORY OR OTHERILOCATION
<br />,( Central Nebraska Cremation Services
<br />t7a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City ,r Town, State)
<br />Ail Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CIT1k/ TOWN
<br />Gibbon I
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events. disuses, injuries, or complications -that directly caused the death. DO NOT enter tannins! events such as cardiac arrest,
<br />nepkatpry west, or Yorplpuar radiation without showing the etiology. DO NOT ABBREVIATE Enter only one cause art a line. Add additional lines It' necessary.
<br />IMMEDIATE CAUSE:
<br />REMDIATECAUSE IFi►el a)End Stage Renal Disease
<br />dI«a►oreondklaa rem
<br />In death)
<br />:aw4.ntteiry est sondiusm; l(:.
<br />any,' tending*, gatr eaues gated:
<br />on Rae a.
<br />Enter die UNDENLYINO CAUSE
<br />(diseses or Injury that kdtated
<br />the events resulting In death)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse .::. .. :: ...
<br />lac. DATE (N , Diy ,Yr,I;
<br />March 7, 2048
<br />Nebraska
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Diabetes Mellitus
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />e)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ie. PARTS. OMER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting -In the underlying cause given In PART I.
<br />Congestive Heart Failure, Coronary Artery Disease
<br />SO. IF FEMALE:.;
<br />104114Ml:vg ikon or
<br />ElOooniiiii etil a e4....
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />..:.❑ Not pregnant, put p e ruse 4.1 days tot year before death
<br />❑ Unknown tl p regnant wt9a ste past year
<br />22a: D E.OF IN URY (Mo„'Day, Yr.)
<br />22d:INJURY AT WORK?
<br />DYES ❑ NO
<br />216 MANNER OF DEATH
<br />® Natural ❑ ROistekle
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑: DdvsrlOperator
<br />❑: passenger
<br />❑ Pedestrian
<br />❑. Other (Specify)
<br />onset to death
<br />> �Monttts::.
<br />onset
<br />IS. WAS MEDIC. SXAMINER
<br />OR CORONER CONTACTED?
<br />' QYes..:::...®;►o
<br />21c. WAS AN AUTOPSY PERFORMED? ::
<br />❑ YES ®NO•
<br />21d WERE AUTOPSY FINDINGEAVASJU
<br />TO COMPLETE !lEtst{,Of DEATH?
<br />El YES
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />/
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ear. tOCAnoN:OP INJURY' STREETS. NUMBER, APT'NO. CITY/TOWN
<br />23a. DOE OF DEATH (Mo., Day, Yr.)
<br />March 5 2018
<br />. DATE SIGNED, (Mo., Day, Yr.)
<br />Match 6 2018
<br />23c. TIME OF DEATH
<br />07:38 AM
<br />33d TEgia bat Of my knowledge, death oceurled at tine time, datrand place
<br />enddlte toll* cause(s) atated. ialgneture and Title)
<br />Bin K. Buhlke, DO
<br />IS. DID TOBACCO USECONTRIBUTE TO THE DEATH?
<br />i❑ YES NO CI PROBABLY ❑ UNKNOWN
<br />26a. HAS 0
<br />❑ YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TUSE OF DEATH
<br />24d. TIME
<br />24e. On the basis of examination andlor imsstleetIon, In my opinion oseM80ciinsd at
<br />tie tine, dab and place and due to tin cause(*) stated. 6Ngnskseall6TNls)
<br />OR TISSUE DONATION BEEN CONSIDERED?
<br />11 NO
<br />21. NAME,TITL *ID ADDRESS OF CERTIFIER (Tips or Prin
<br />Brian K. Buhlke, DO, 2510 18th Avenue, Central City, Nebraska, 68826
<br />Zee REGISTRAR'S SIGNATURE,,
<br />arboigA-
<br />26b. WAS CONSEGRANTED?
<br />Not Applicable If 26a is NO OYES
<br />tab. DATE FILED BY NEGISTROVI1MO,:i
<br />March 12, 2018
<br />•
<br />
|