|
4400111
<br />„r •,"`.".."i .n rr . r .rr.r;/111111/ `��.a
<br />l 1 ` / r5 i C
<br />;ts$f/1y��`r?a3�4;11i411e3�,rwa���31�1�4�1$4tP_dw��,ti�tl3,,,/;4ti_,4,)s�i;,�.�itt4'1`),i�1�E�31_I_�wti�,st311),��,)(flaNdAarn;$a� �s,1a4669A�.11ltlrS;:�4r!,C�4r:0ei:ai�.��ii lli�(i9�;f/il4riS!i!Y•r'llr,rr �14!r%liil
<br />a1 1 .._� - - -- 8 n i1. a n,,, ;Jt(cct.
<br />�a> > f � 1»�) acc 11 11)t
<br />$ail lrr (1 aa A 'Ilij,;dttNw 2.1 ISfox,-,,. r,m r a as I utrt.t4q rttt ra!r5'ir lr' O""I* ' *�tr N{)riilVl'Il' 'Mfg
<br />aril 'jib rnr1l\ 1 Dyl!/%1%l�ii 1, 1i \�r'ri5r!�r5
<br />t46'i1�1�P11)' acay..,<x6�Y449yA:riha . a, ,v,aa t54iltTlihlt)tcn> - 4. %(15r✓I'flilttlCi� ,dfi/'N'QINDD eryEl;
<br />.. <:.2✓.. . ,.�h.:, ... -.-z:�a.:.�,.,s
<br />STATE OF NEBRASKA )
<br />WHEN pis 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 />HUMANSERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/11/20 3
<br />UNCOLN, NEBRASKA
<br />2026n2347
<br />SARAH ROHNENKAMP
<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. DEMENTS -NAME i(First, Middle, Last, Suffix)
<br />Allan
<br />Joseph Layman
<br />4.Girt AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Watertown, Minnesota
<br />'7 SOCIAL SECURITY NUMBER
<br />471 62 2214
<br />64. AGE - Lilt Birthday
<br />(Yrs.)
<br />77
<br />eb. FACIUTYrNAME (W not Institution, phis street and number)
<br />1204 Kennedy Drive
<br />ec CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />bb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />ea: PLACE OF DEATH
<br />.:HOSPITAL Q.Inpatisnt
<br />❑ ERiOutpatlent
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />ec. UNDER
<br />HOURS
<br />23 11979
<br />3. DATE OF DEET911918 ,Day; Yr )
<br />August 26,, 023
<br />1 DAY 6. DATE OF BIRTH (Mo.;.Day `"Yr.) `>
<br />MINS.
<br />March"l9 .i 948:
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />Ied. COUNTY OF DEATH
<br />Hall
<br />0 fospiee Fac)Ilty
<br />lid veeer Aftp NUMBER
<br />1204 )Celtnedy Drtve
<br />Ile. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />4g.I► DE:Str E:1Rn'E;
<br />164MARITAI: STA1V3 AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nine
<br />Cynthia Woitalewicz
<br />11. FATHER'S -SANE (First, Middle, Last, Suffix)
<br />Robert Thomas ::Layman
<br />13:::EVER?IN U S AEMED'FORCES? Give dates of service B Yes.
<br />rise, No, orUnk.)Yes 08/04/1964-04/16/1967
<br />14a. INFORMANT.NAME
<br />Cynthia Layman
<br />12. MOTHER'S -NAME (First, Middle, Malden Sumams)
<br />Doris McCann
<br />14b. RELATIONSHIP Tt'I'DECEMENT
<br />Spouse
<br />11L METHOD OF DISPOSITION
<br />BUrbll [ Do Cation
<br />Cremation [Entarnfbmsnt
<br />1 Ramovari ` ❑ other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />lea DATE (JIIQ, Dtgr, Yr ),
<br />September 10 2023'
<br />STA'iE
<br />Nebraska
<br />17a,.FUNERAL, HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />1Tb.
<br />68801:
<br />CAUSE OF DEATH (See.ir structions.and examples)
<br />1L PART I. Enter the chain of avant- 411 .awe, InJurNa, or complications -that directly cauaad the death. DO NOT enter terminal events such as cardiac arrest,
<br />mapkatory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ono cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />M saouti cAttse demo a) metastatic renal cell carcinoma
<br />elms or eaed*len ihheIMl$>
<br />in destht .... ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially get conditions, If b)
<br />any, leading to Ms OWN caved
<br />OA Mt IL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Worth,UNDF.RLYINecouse C)
<br />(Mum or nJrirY:utat rriiiiidad
<br />the evunte resulting n death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />16 PART U OTHER SIGNIFICANT CONDITIONS.Conditions contributing to the death bUt not rssutting In **underlying cause given In PART I.
<br />Chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation, type 2 diabetes mellitus
<br />APPROXIMATE INTERVAL
<br />onset* doSti
<br />18 Months
<br />onset to death
<br />onset to death
<br />1e. WAS MEDICAL rn APNER
<br />OR COROHER'CONTACTED?'
<br />❑ YES ®NO
<br />20. IF FEMALE:.:
<br />elet lkeen. mt IWi*0 pset:Iraar
<br />❑ PreiMntat lrMdesea
<br />El. Not yMgrNlnt, but pregnant moon 42 days of death
<br />❑ Net pregnant, but pregnant 43 days to 1 year baton death
<br />.: ❑..ifnknown Ntsagnentwithn the past ysar
<br />21a. MANNER OF DEATH
<br />Natural 0 Homklde
<br />❑ Accident 0 Pending Inwaetigatwn
<br />0 Suicide ❑ Could not be determined
<br />21b.:IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />El Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY'PINOINfi>f AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />221. DATE OF *N,1URY (M:O: Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, ofncs building, construction stie, I) Wear)
<br />22d. INJURY AT WORK?
<br />0 YES.:: ❑ NO
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />22E LOCAIION'OFINJURY STREET d NUMBER, APT.NO.
<br />CITYITOWN STATE
<br />ZPCODE; :;
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 26, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />August 28..2023 •10:40 AM
<br />Tatbelease of:isyknoewdge, death occurred at Ma thew, data and piece
<br />atltl due to the Cassels) stated. (Slgnsture and TRIM
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE. CONTRIBUTE TO THE DEATH?
<br />1»"J YES CI NO ] PROBABLY ® UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD;,,.
<br />2p.:Qn tite basis of examination and/or kwestigation, in my opinion death uaumd at
<br />t . tkna, data and place and dus to the camels) stated. ($Nnatwe Stela>tM e)
<br />26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 50NO
<br />270 NAME, TITER AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth MD 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26a. REGISTRAWS SIGNATURE`y , Jim.4 k.04 7t7 1.
<br />2eb. WAS CONSENT GRANTED?
<br />Not Applicable B 26a le NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 6, 2023
<br />H
<br />00
<br />
|