|
ni lkiMINSI
<br />hiiglNlfttEtly4% m,1CClIii))f(INii; -'
<br />STATE OF NEBRASKA
<br />1IretlY" Y4t4.95 4('Ill)tdsa T .rozlcii'A�r�v
<br />ftt1419'1711111tP>'t n/rr�tV
<br />\. WHEN TI#IS COPYCARRIES:'THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIF'JES:THE DOCUMENT BELOW TO
<br />SEA;•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 />iI
<br />DATE OPISSUANCE
<br />4/6/2026
<br />LINCOLN, NEBRASKA
<br />202602143.
<br />SARAH BOHNENIKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH'.
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 DECEDENT$ -NAME )17et .... Middle, linft, Suffix)
<br />Mein Lenwis Sutton"
<br />CERTIFICATE:OF DEAT•
<br />4 CITY ANOSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, ::Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />507-781627
<br />ib. FACILITY -NAME (If not Institution, give street and number)
<br />403 N 2 d St I
<br />to, CITY OR TOYVN OF DEATO (include Zip Code)
<br />DONOR et 68832
<br />911. RESIDENCE -STATE
<br />Nebraska
<br />9d:ETRESTANb NUMBER
<br />403>I 2nd St
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS ATTIRE OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />It �ATHER S NAME (FU$t
<br />Lewis Sutton
<br />Iddle, Last, Suffix)
<br />13 EVER IN U.$. ARMED FORCES?
<br />(Yes, No, or link.) No
<br />1e. METHOD.OF DISPOSITIQN
<br />Burial ❑Donation
<br />] Cremation ❑Entot
<br />❑ Removal 0 Other (Specify)
<br />Give dates of service if Yes.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a. PLACE OF DEATH
<br />HOSPITAL ❑,Inpatient
<br />0 ER/Outpatient
<br />❑;DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />224'120
<br />3. DATE OF DEATH(Mo,,:.:Day, Yt,)
<br />August 29, 2024:::
<br />6. DATE OF BIRTH
<br />OTHER ❑ Nursing HomafLTC
<br />® Decedent's Home
<br />❑ Other (Specify) x
<br />6d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE'
<br />68832
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lynne Killion
<br />14a. INFORMANT -NAME
<br />Lynne Sutton
<br />16a. EMBALMER -SIGNATURE I
<br />Not Embalmed
<br />9e. APT. NO.
<br />12.:MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Virginia Norman
<br />16b.LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION ` CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />1Ta ,FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale)
<br />All Faith$ Funeral Home; 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1e. PART I. Enter the chain of events- -diseases, injuries, or complicatione4hat directly caused the death.,DO NOT enter terminal events such as cardiac ar fst,
<br />respiratory arrest, or ventricular fibrillation without slowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line,. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) carcinoma
<br />IdMEDutTE CAUSE tonal
<br />mesas* or coadit(On•
<br />$fulting�
<br />hi death)
<br />8equentlafy list conditions, If
<br />anY:')ead ng tpitM cauliddet d
<br />lire
<br />online a.
<br />::Anter hire teltertt.Yise CAUSE.:
<br />(tlbease or injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />4&:PART IL OTHER SIGNIFICANT CONDITIONS -Conditions con rt ibuting to the death but no; Om
<br />20 #F:;FEMAtE
<br />.❑: NotpregnaifWitltinpaatyear
<br />❑: PrepnrntstlhnsrNdlaath
<br />{_ .Not pregnant, but pregnant within 43 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />{HAm4uattfpregn ntaillntliehastyear
<br />22e.€DATE OFiNlURYIM0.,Day, Yr.).
<br />22d. INJURY AT WORK?
<br />#-t YES'::::;❑ No
<br />21a. MANNER OF DEATH
<br />Natural ❑ Netni de .
<br />❑ Accident ❑ Pending Investigafon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />dreg in the underlying cause given iWPART I.
<br />21b: IF TRANSPORTATION INJURY
<br />DrrverlOprrator
<br />o Passinger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />1412. RELA1
<br />Spouse
<br />16c, DATE (Mo., G
<br />September 4; 2£I'ra
<br />N,
<br />90.1111SIDEITYUII
<br />Y �D:l
<br />TO DECEDENT"
<br />STATE
<br />ebraska
<br />19. WAS MEDi0AL.:R
<br />OR CORONER CCft'ACTlED? .
<br />OYES
<br />21c. WAS AN
<br />❑YES
<br />21d. WERE AUTOPSY FIiDINC AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES D NO
<br />22c. PLACE OF :INJURY At home, farm, street, factory, office building, construction site, eto. t
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f 1:OCATiON CF INJURY. BEET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 29, 2024
<br />23b DATE SIGNED (Moe Osy, Yr.) 230. TIME OF DEATH
<br />September 6. 20 4 02:35 PM
<br />i!Sd. To tin boll ef myt tnow$edgs, death occurred at the time, date and place
<br />out due to tan Haute(si stated. (Signature and Thin
<br />Julie Fletcher, MD
<br />TOBACCO US$ CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO PROBABLY ❑ UNKNOWN
<br />2T NAME, Td11 E AND A OF CERTIFIER (Type or Print
<br />Julie Fletcher, MD, 715 N St Joseph Ave, Hastings, Nebraska, 68901
<br />25- DID
<br />26a. HAS ORGAN OR
<br />OYES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d,
<br />34e. Oltlhe beau* of examination and/or Investigation, in my *pinion death occurred a
<br />the thrie;`date and place and due to the causes) stated. (Signature and h is) '
<br />Tissue DONATION BEEN CONSIDERED?
<br />IR' No
<br />26b. WAS CONSE
<br />Not Applicable If 26e.is NO
<br />28b. DATE FILED BY
<br />September 6,
<br />
|