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<br />STATE OF NEBRASKA
<br />�I�irr , 1r a41'R4)I)0iiN'F atBt�iYYY�A1A1erQ� , sagdt4t'I.IR:1't1Rt?rtx, �
<br />WHEN THIS COPY CARRIES' THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE cOPrOF THE 1NAL 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 />1
<br />i
<br />Pr
<br />f
<br />BATE t ISSUANCE< i'
<br />' 116/2026.
<br />LINCOLN, NEBRASKA
<br />f :DECEDEr T 7S.?IAME:;(Fitst, Middle, Last, Suffix)
<br />Derek A Hays
<br />SARAH BOHNENIAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE QF DEATH.
<br />4. CITY AND STATE' OR` TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />SCOttSbki f,::Nebraska::.
<br />T SOCIAL SECURITY NUMBER
<br />508-15-6683
<br />lb. FACILITY -NAME (If not Institution, give direst and number)
<br />1.721 bleat Anna St;..,...
<br />Sc 'CI:TY OR TOWN OF DEATH: (include Zip Code)
<br />Grand Island 68803'
<br />9a. RESIDENCE -STATE
<br />>>Nebraska
<br />9d. eTREET ARm'fIfU ogR
<br />1721 Weft Anna St
<br />9b.000NTY
<br />Hall
<br />100. MARITAL STS.TUe AT TIME OF DEATH 0 Married ® Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11:::FATWER!g<MAME
<br />Allen . l!'11 ys`
<br />Middle, Last, Suffix)
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yt s, No, or Unk.) No
<br />15. METHOEVOF DISPO$(T1ON
<br />BUrhti 13Donation;<
<br />® i ronation : ❑ Entombment
<br />0 Removal 0 Other (Specify)
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />42
<br />5b. UNDER 1 YEAR
<br />Mos.
<br />DAYS
<br />Sa. PLACE'OF DEATH''
<br />HOSPITAL ❑:Inpatient'
<br />❑ ERlOutpatient
<br />❑ Don
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />Found Dece0Ml€ tq
<br />S. DATE OF RRRTN Into:, Day, Yr.)
<br />June 25, 1 ::
<br />OTHER 0 Nursing Horns/LTC
<br />® Decedent's Homy
<br />0 Other (Specify)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />9p, APT. NO.
<br />St. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Shawn Arora
<br />16s. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />12.MOTltER.'S.NAME (First, Middle, Malden Surname
<br />Shawn Huxoll
<br />10d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />13b: LICENSE NO.
<br />11439
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a,.FUNE SAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stlge)-
<br />All'aithlB FuneratHome, 2929 S. Locust Street, Grand Island; Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />tt PART(. Enter the c of vests- 4laseaSe, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />raapkatm w vetdriealarfibrilatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one came, on a tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE IFhal ..:.
<br />dlasaw:or condition musing
<br />5) Unknown Natural Causes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequoias* ilsteonditions,if b)
<br />any; tesdfitg:to ui. came
<br />I rnerttie UNOERLYItIQ CAUSE 'C)
<br />.(diaaee or injury that Mtilsted
<br />the ,win hs resulting hadaath)
<br />t,AiT /
<br />OR AS A CONSEQUENCE OF:
<br />DUE TO, OR -AS A -CONSEQUENCE OF:
<br />. <.d)
<br />#iS PART fi Caner SiGNIFit ANT CONDITIONS -Conditions contributing to the death but
<br />20 IF FElMMALE
<br />I Not pregnant within pest 1nar
<br />Pregnantetdnl Wdespl "::
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant43 days to 1 year before death
<br />uMctldwh a pregnant wgntin lM peat year
<br />.22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />CINO
<br />tfsun ing:In the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Noadoida
<br />❑ Accident ❑ Pendinginveatig*tlof
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Of Drlyer/Operator
<br />LJ p"pnger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Mother
<br />1Sc. DAIS (Mo., Day, >ir.
<br />December 22,.:202
<br />: STATE
<br />Nebraska
<br />17b Sip Got
<br />8a80.1..
<br />to
<br />r
<br />1e. WAS
<br />dR CORD
<br />21c. WAS AN AUTOPSY PERFORMED?';
<br />©YES,_
<br />21d. WERE AUTOPSY FIN0I
<br />TO COMPLETE CAUSE
<br />❑ YES ©,
<br />22c. PLACE OF INJURY -At hom., t nn, street, factory, office building, construction sits,,.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJURY STREET A NUMBER, APT.NO.
<br />fv
<br />i
<br />E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />231fDATE SIGNED lMo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />32d To the best of my:knowledge, death occurred at the time, data and place
<br />.?and du. a to the eaua(al stated. (signature and Title)
<br />*pm TOBACCO USIE CONTRIBUTE To THE DEATH?
<br />��r YES NO PROBABLY UNKNOWN
<br />2T. NAiw TITSA AND ADDRESS QF CEa'fFIER (Type or Print
<br />Martin Klein; Halllounty Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />#tie REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 19, 2025
<br />20.1110 OP DEATH
<br />Unkn rw�tn
<br />24o. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED
<br />December 17.2025 10:13 AM .
<br />24*.On the basisof examination and/or investigation, M my opkttan death
<br />the time, date and place and due to the causels) stated. (Signature as d
<br />Martin Klein, Hall County Attorney
<br />25b. WAS CONSENT GRANTEU'i'T'
<br />Not Applicable If 21Ia Is NO
<br />29b. DATE FILED BY REGIS
<br />December 30, 2025
<br />
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