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<br />STATE OF NEBRASKA `/
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<br />ONATION
<br />WHEN THIS COPY RRIES THE RAISED SEAL OF STATE OFNEBRASKA; IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUECCARRIES
<br />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 OFISSUANOE
<br />4/6/2026
<br />LINCOLN,NEBRASKA
<br />202602240 jeuittil 8, .l .
<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 />DECE.DEISTh.N IME':.{Ft1L Middle, Last, Suffix)
<br />Shannon iYlarlsr ticCoy
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Joliet 18ingis
<br />SI5I/11. sECURrTY Nl1NR
<br />32864-1997'
<br />5a. AGE - Last Birthday
<br />58
<br />Sb. FACIUTY-NAME (If not blsttutlon, give street and number)
<br />212 ..10th:;Street
<br />Si:. PITY_ Ctr;tO OF p Th (Include Zip Code)
<br />Grind lsladd 68801
<br />es. RESIDENCE -STATE
<br />Nebraska
<br />SA. STREET AND .'NUMBER
<br />212 EaOth>Btreet:::
<br />Ob.COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH [ Married 0 Never Married
<br />® MMala4, but.upended ❑Widowed 0 Divorced ❑ Unknown
<br />li FATHER'S -NAME (First, >: Middle, Last, suffix)
<br />Stanley uiield>
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Se. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea: PLACE OF DEATH
<br />HOSPITAL O'patient
<br />❑ ER/Outpatient
<br />©DOA
<br />HOURS
<br />MINS.
<br />3. DATE Or PEXIN.IMO., Li My Yr j
<br />Found March i2026
<br />S. DATE OF BIM (Mo., Day, Yr.)
<br />August 17, 1970.
<br />OTHER 0 Nursing Horne/LTC
<br />I Decedent's Home
<br />0 Othe►(SPy)
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />[;f NeapleeFalliriiyy
<br />I INSIDE CITY LOTS'
<br />l> s
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) it wife, give maiden name
<br />Stephen McCoy
<br />'12. MOTHER'S:NAME (First, Middle, Maiden Surname)
<br />Nancy Burosh
<br />Sc. CITY OR TOWN
<br />Grand island
<br />Se. APT. NO.
<br />Sf. ZIP CODE
<br />68801
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk) No
<br />0:.11 MEm000FolsP£1srnoN
<br />0,1al 441Dwlstlolz
<br />6t1'cr ii auofi 3 6lidditinient
<br />0 Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Stephen McCoy
<br />16e. FUNERAL DIRECTOR SIGNATURE
<br />Katie A. Smydra
<br />16d. CEMETERY, CREMATORY OR OTHE(2 LOCATION
<br />Central Nebraska Cremation Services
<br />1fia FLJ I .NE NAMY AND MAIUNG ADDRESS (Street, City or Town, State)
<br />AH F * Funereal Nome, 2929 S. Locust Street, Grand Island, Nebraska.
<br />16b, LICENSE NO.
<br />1454
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1a. PART I. Hoer the Main of events- .dlawaa, Iblurlaa, or complicationstlet directly/Caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />nspinrtpry MOM, or veMdcular/Wrialbn without t showing the etiology DO NOT ABBREVIATE. Enter only one u atrae OR line, Add additional tines a neeaery.
<br />IMMEDIATE CAUSE:
<br />IATE ABNIPIPInt6 _.. a) Unknown Natural Causes
<br />.
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />..>N,4unnlN.Il Met c n iuoml:M>;:.b)
<br />.: >I. N111111gtptlM.1}�tlNtfated,.:;,
<br />!In Iltls a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />8Endwise fsiaRLWNOCAUas c)
<br />'$ (disease or injury Met Misted
<br />the events mndling in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Ts. PARTS. OTHER SIGNIFICANT pONDITIONS.Conditions contributing to the death but not resulting In the underlying cause given in P
<br />Hypertension
<br />t10 lF FEMALE
<br />list pm6nsntwifda peat year>
<br />❑ inn xlmettnMofdtilll.::>:
<br />0 Not pregnant, MR predeath poignant within 42 days of
<br />CI Not peptised, t, but pregnant 43 days to year before death
<br />iIMInsibi If sfaimentwitithilivepestyear
<br />22a. DATE
<br />IN..u'r NIa4Day, Yr.)
<br />•
<br />22d. INJU,AT WORK?
<br />21a. MANNER OF DEATH
<br />® Natural El Ham**
<br />Accident ElPending Investigation
<br />0 suicide 0 Could not be detemnined
<br />22b. TIME OF INJURY
<br />214. IF TRANSPORTATION INJURY
<br />❑:PfiW. r/operator
<br />Ihuunper
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband -::
<br />16c. DATE (No ,i
<br />March 16, 2026
<br />STATE
<br />Nebraska.
<br />nth Zip CC
<br />688Ct:1
<br />APPROXIMATEINTERVA.-
<br />onset ta
<br />Unknown;::;
<br />onset to
<br />l
<br />ART I.
<br />19. WAS MEDICAL, EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES :;Q NO...
<br />21c. WAS AN AUTOPSY.F.ERFOR$ED7
<br />E7 YES ®NtT=
<br />❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE(
<br />❑ Other (Specify)TO COMPLETE cause OF,DEATN:.,
<br />❑YES El NO.;::
<br />22e. PLACE OF INJURY ALbotne, farm, street, factory, office building, construction sits, etc: 12psdly
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />/; 22f LOCATION OF INJURY STREET& NUMBER, APT.NO.
<br />S
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />3b DA ... S1GNNS;(Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />l.::TS best of, m,)t.knoal dgs, death occurred at the time, date and place
<br />"end MO othetbuseis) stated (Signature and MN)
<br />;ai is T CCOi;USE CONTRIBUTE TO THE DEATH?
<br />II YES "WOLIUOROBABLY ❑ UNKNOWN
<br />26e. HAS ORGAN OR
<br />❑ YES
<br />NAIVIS,17 D ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska,8801
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April.1, 2026
<br />24o, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March & 2026
<br />211a. REGISTRAR'S,.SIGNATURE
<br />IIEEN CONSIDERED?
<br />24b. TIME OF DEATH
<br />Unknown .:.:
<br />Y...l
<br />24d. TIME PRONOUNCED
<br />07:20 AM
<br />24s.'onthe basis or examination and/or investigation, In my opinion da.I4 oc fared al
<br />the time, date and plan and due to the counts) sated. ($Ignites bad WM)
<br />Martin Klein, Hall County Attorney
<br />2Sb. WAS CONSENT
<br />Not Applicable If 26a Is NO
<br />26b. DATE FILED BY REGISTRAR
<br />April 3, 2026
<br />lfl
<br />
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