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<br />� - STATE OF NEBRASKA
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<br />WHENTHIS COP' CAI' /ES THE RAISED SEAL OF STATE OF NEBRASKA,17 CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUECOPYOFINEORIGINAL 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 OP ISSUANCE
<br />• 3131 /2026
<br />LINCOLN, NEBRASKA
<br />s3
<br />w
<br />9
<br />1
<br />202602636
<br />M
<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 />t DECEDENTS -NAME (First,. ,: Middle, Last, Suffix)
<br />WaYMle E''E leaeon
<br />4. CITY AND STATEIR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />t=;eartwell, Nebraska
<br />7 'SOCtAL SECURITY NUMBS ;/
<br />5054.38 7325
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />lib. FACILITY -NAME (If not institution, give strait and number)
<br />Tabitha at Prairie Commons
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island ::68803''
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d:::SmEET`AN. NUMBER
<br />3490 EYYO1dt.St
<br />9b. COUNTY
<br />Hall
<br />1tle. MARITAL. STATUS ATTIME OF DEATH I Married ❑ Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />11 FAT.HEW$ NAME (F#bt,''
<br />Charles Gleason
<br />Middle, Last, Suffix)
<br />13. EVER tit U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes
<br />15 METHDD QF DIsPos lOnN,
<br />etlflai �oon.d
<br />® CiinaaSon ❑. EntOmb n nt
<br />❑ Removal ❑ Other (Specify)
<br />86
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />O ER/Outpatient
<br />▪ DOA
<br />9c.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OP DEATH**o
<br />March 13, 2026
<br />Day,'Yr.)
<br />6. DATE OF MRTN (Mo., Day, Yr.)
<br />July 22,
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />® Other 18peeKy)ASSISTEDt;:MNt °
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ile. APT. NO.
<br />20-1
<br />9f. ZIP CODE
<br />68803
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sharon Bottorf
<br />14a. INFORMANT -NAME
<br />Lori Beck
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1h FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />AEI Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Gertrude Baker
<br />t6b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART L Enter the chain der evaMs- dkuases, injuries, or compllcatlons4hat directly caused the death. DO NOT enter terminal *vents such as cardiac arrest,
<br />rwpkaloty, arrest, or verddcutsr fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one awe on a Nne. Add additional fins N necessary.
<br />IMMEDIATE CAUSE:
<br />*.08081E CAUSE 4Fkxil .
<br />rbleeetiiortond<fianraNdiln <:
<br />a aintraparenchymal hemorrhage
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />seguwslaiy 1st conditions, N b)
<br />*Denis. njttalltscels►N*4
<br />O1lE TO, OR AS A CONSEQUENCE OF:
<br />.14nertilt itiggRLYN4ti.CAIfRE.;.::C)
<br />(disease or IMury that Mmlated
<br />tied *veins ruining 1n de.M) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAIT
<br />a)
<br />18 : PART ti. OTHER SIGNIPI.CAiNT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />pneumonidiabetes mellitus type 2, chronic hypoxic respiratory failure •
<br />2Q W FEMALE
<br />Pnprwnta Uunsctdsl4
<br />El Net pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Uu11sorm lfpn¢aemt OOPffiri paai yaw
<br />DATE °FINJURY (M.8 Days Yr.)
<br />22d. INJURY AT WORK?
<br />::'❑5:::❑KfY:i:
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending hrvaatlgation
<br />❑ Suicide ❑ Could not be dewnnined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 DthwrlOperator
<br />Passenger
<br />❑ Pedestrian
<br />❑ other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />19c. DATE (Mo., Bat W.:
<br />March 16, 20
<br />aTXTE
<br />Nebraska
<br />onset to death
<br />onset to dslth : a
<br />onset to death
<br />19. WAS MEDICAL(akAMBNER."::''
<br />OR CORONER CONTACTED?
<br />❑ YES 55 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDING¢ AYAIIAeI.E
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ❑NO
<br />22c. PLACE OF INJURY -At ttome, farm, street, factory, office building, construction site, etc.:0001M
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22E1.0 TKtN OF INJURY. STREET 8. NUMBER, APT.NO.
<br />8
<br />A'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 13, 2026
<br />CITY/TOWN STATE
<br />231xDATE $IONED:(Alo., Day, Yr.)
<br />March '16 202s.
<br />23c. TIME OF DEATH
<br />04:55 AM
<br />231L tolfie:kwt:of:le.Y:knnWMdgs, death occurred at the time, date and place
<br />a1aA duii thf atltiti(s) dated. (signature and Two
<br />Ryan D Crouch, DO
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />GODS:
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED F'
<br />24e. On the basis of examination and/or imestigedon, In my opinion death etWAT 2j11
<br />the tin*, ate and place and duo to the cauree(s) stated. (signings nod TWO)
<br />36.. D D TGBAC O USE CON'#'lpBUTE TO THE DEATH? 26a. HAS ORGAN .OR. = , • TION BEEN CONSIDERED?
<br />�I YES .,; NO ❑ PROBABLY ❑ UNKNOWN 0 YES i t
<br />NAME, T1Tt:E'AND AGpREBS OF CERTIFIER (Type or Print
<br />"'Ryan DCrouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68 1
<br />26a. REGISTRAR'S S1GNATU
<br />26b.WAS CONSENT ORAN so?:;..;'
<br />Not Applkabl.N 26a Is NO C'J
<br />28b. DATE FILED SY REGISTRAR (Mq.;Day Yr.)
<br />March 20, 20.26
<br />7
<br />W.w
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