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<br />STATE OF NEBRASKA
<br />°"tt44661Bif11tv1ea - .rr44,yrpMc
<br />WHEN THIS 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 />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />1
<br />0
<br />a
<br />`DATE OP ISSUANCE'
<br />12/16/2024
<br />LINCOLN, NEBRASKA
<br />202602658
<br />�.� 8A44.41
<br />�
<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 />1, OECaDENT'SAIAME '(First:: Middle, Last, Suffix)
<br />Danny Ray Conley
<br />CERTIFICATE OFpEATH,.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />;Tribi,me, Kansas
<br />7 SOCIAL SECURITY "NUMBER
<br />5t2-58.546D
<br />(lb. FACILITY -NAME (If not Institution, give street and number)
<br />1925 Freedom 17r
<br />Sc. CITY Oft TOWN OP DEATH (Include Zip Code)
<br />Grand (Slant 60803
<br />9a. RESIDENCE -STATE
<br />.Nebraska
<br />Sd: STREETAND::NUMBER ;::
<br />1925 Freedom Dr
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />11 FATHER'S,rNAME (First,.:,. Middle, Last, Suffix)
<br />Ritttarrf Conley
<br />13. EVER IN U.S.' ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />i5:M ETHOD OF QISPOE(TION
<br />Burial 0 Donation).
<br />❑ Cremation Entombment
<br />0 Removal ❑ Other (Specify)
<br />AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />fib. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />❑ ER/Outpatient
<br />CI DOA
<br />9e. CITY OR TOWN
<br />Grand <Island
<br />HOURS
<br />MINS.
<br />24:14819
<br />3. DATE OF DEATH (Nit., DAyt Yr,)
<br />December 5, 2024
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 28,.4914,
<br />OTHER 0 Nursing Home/LTC
<br />IE Decedent's Horns
<br />0 Other (Specify)
<br />ISd. COUNTY OF DEATH
<br />Hall
<br />�e APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />D taisplcs Fsa lfty
<br />fr MB4 E Cfl'Y urarre
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Mary Vanosdall
<br />144. INFORMANT -NAME
<br />Mary Conley
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHERTS-NAME (First, Middle, Maiden Surname)
<br />Daisy Birch
<br />iSb. LICENSE NO.
<br />1495
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Grand Island City Cemetery Grand Island
<br />7Ta FUNERAL Ht k: E NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funerai Hotte, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and ttxamDles)
<br />is. PART I. Enter the chain of events- -diseases, injuries, or compilcatione4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation vdthout showing the etiology. DO NOT ABBREVIATE, Enter only one caw' on aline. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE cAUsE(trrnat a) respiratory failure
<br />disease or cowman musing -
<br />in death)
<br />Sequentiallylist condition*, if
<br />any. Meiling M t s q use ll*g6
<br />en fine 1.
<br />inner trtiiUNDERLmo,m CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting M death)
<br />tAlT
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) pneumonia
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />►
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />16. PAFrr it,: OrhER. SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resuitingin lheunderlying cause given in PART I.
<br />chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, atrial fibrillation, pneumocystis pneumonia, diabetes
<br />mellitus type 2
<br />2G IF FEMALE
<br />❑ Nt+l prepmFm•within Mtn ye r
<br />•
<br />❑ Ptupnant st tidal Oy deaM
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant N days to t year before death
<br />0 Unknown prlgpt*nt wN,In tM pest year
<br />22s. DATE OF ,44URY (Mo.: Dey, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />El Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At home,
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo, Day',7..t:)
<br />December 1, 2024
<br />$'LATE
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />onsettodsser."
<br />2 Months
<br />onset to death
<br />2 Months
<br />onset to fiklstB�'
<br />onset to desel
<br />19. WAS MEDICA1EXAMINER.
<br />OR CORONER CONTACTED?
<br />D yes .. 0I No
<br />21c. WAS AN AUTOPSY(PERFO
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ Yes ❑ NO
<br />farm, street, factory, office building, construction site, etc.
<br />22d. INJURY AT WORK?
<br />D.YES.. ❑MO ..._..;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET i NUMBER, APT. NO.
<br />CITY/TOWN STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 5, 2024
<br />23b DATE SIGNED:4Mo., Day, Yr.)
<br />Del iTlber 6,'2024
<br />23c. TIME OF DEATH
<br />Unknown
<br />*TO It .b at of my:hocsledge, death occurred at the time, date and place
<br />:... srta tlu►ao thi!dshsejs) stated. (Signature and mill
<br />Isaac J. Berg, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑; YES NO D,PROBABLY El UNKNOWN
<br />O A
<br />E, DpRE88 OF
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24C:
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED:fEAD
<br />tie.On (0461*11 of examination and%or Investigation, in my opinion death oopujsid at
<br />"'tM tints, date and place and due to the cause(s) stated. (Signature and BIM
<br />26a. HAS ORGAN OR' = • ATION BEEN CONSIDERED?
<br />❑ YES i7 NO
<br />S.T. NAM TITLE
<br />CERTIFIER (Type or Print)
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE x,7 g
<br />26b. WAS CONSENT GRANTED?
<br />i.
<br />Not Applicable if 26a Is NO DYES { NO >
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />December 11, 2024
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