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<br />pkO t'l' 1i�t1a+laAlr, r,trSITATE OF NEBRASKA
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<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 />t
<br />a
<br />I
<br />DATE OF ISSUANCE
<br />8/29/2025
<br />LINCOLN, NEBRASKA
<br />-202603433
<br />// I.4
<br />SARAH BOHNENKAMPP
<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.OECEDENTSNAME (First, Middle, Last, Suffix)
<br />Phyllis Kathryne Long
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />GrandT1sland, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />506-46-1412
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (I not institution, give street and number)
<br />Tiffany Square Care,Center
<br />Sc. CITY OR TOWN OF DEATH(include Zip Code)
<br />Grand Island 68803
<br />fNL RESIDENCE -STATE
<br />Nebraska
<br />ad. STREET AND NUMBER ".
<br />20'sViaTrivoli
<br />lib. COUNTY
<br />Hall
<br />1oa. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married but separated ® Widowed 0 Divorced 0 Unknown
<br />it. FATHER'S -NAME (First,. Middle, Last, Suffix)
<br />Fred A Kruse
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />® Cremation' ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />86.
<br />lib. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑D
<br />Sc. CITY OR TOWN
<br />Grand Island.
<br />HOURS
<br />MINS.
<br />25115.63
<br />3. DATE OF DEATO4E7.,.
<br />August 18, ?VA:
<br />6. DATE OF RIRTN (aio., Dly, Ye.)
<br />January 28,1
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />lid. COUNTY OF DEATH
<br />Hall
<br />Re. APT. NO.
<br />Sf. ZIP CODE
<br />68803
<br />939
<br />Yr.)
<br />q He plcit Facgity
<br />/
<br />I I
<br />1I0. tItSIDE Ct1'V
<br />Rid
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Steve Long
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Katie M. Smydra
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frieda Stueven
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral HOtne, 2929 S. Locust Street, Grand Island, Nebraska
<br />1Eb. LICENSE NO.
<br />1454
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH'(See instructions and examples)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16e. DATE (Mo D y,' r1
<br />August 20, 2025 '
<br />STATE .
<br />Nebraska`
<br />1nalpedde .;
<br />68801
<br />1a. PART I. Enter the chain of events- -diseases, Injuries, or complleationsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without shoarng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IHIMED*ATE CAUSE (Final a) Failure to thrive
<br />disease or condition resulting
<br />in death)
<br />Sequentially bet conditions, If
<br />taty;1•40149titThecauseNated:
<br />an a.
<br />Enter the UNOERLYINg CI�U$E
<br />(disease or injury that initlJhod
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute delerium
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ft PART II.OTHER SIOMAFICANTCONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Frequent falls and bilateral femur fractures, Vitamin D Deficiency, Paroxysmal atrial fibrillation, Pacemaker, Osteoporosis,
<br />Hyperlipidemia, Hypertension, History Stroke
<br />2II, IF FEMALE: .
<br />© Not pregntmt Within put year
<br />• .0 trnenantettimirOfdeath,
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />D. Unepewn if pregnant tdedtyafe past year
<br />22a. DATE op.INJ)JRY fro!,; Day, Yf
<br />22d. INJURY AT WORK?
<br />DYES. , ONo
<br />22f. LQCATI
<br />it
<br />g
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ ACCIdent 0 Pendinglmsetgetton
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b--.IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />QPassenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onset to del tit
<br />3 Mantles
<br />onset to death
<br />3 Months.
<br />onset to dtttMkll .'
<br />onset to dsalh,.,
<br />19. WAS MEDICALEXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES j NO
<br />21 c. WAS AN AUTOPSY PERFORMED?'
<br />0 YES ®NO
<br />21d WERE AUTOPSY FINDINGS AV Ka
<br />TO COMPLETE CAUSE OF DEATH
<br />❑ YES [j NO
<br />22c. PLACE OF INJURY -At home, fanh, street, factory, office building, construction site, ow. (City) •
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY STREET B NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 16, 2025
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />August 29 2025
<br />23c. TIME OF DEATH
<br />06:40 PM
<br />24Te the•but iNmy kacwledge, death occurred at tie time, date and place
<br />and dui to the:caese(s) stated. (signature and Title)
<br />Kimberly A. Mickels, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ODE.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) DEAD
<br />W
<br />24e. On the bpis of examination and/ly Investigation, in my opinion death santti(d a
<br />the Ilene, date and place and due the eauae(s) atstse. (616utura and
<br />26a. HAS ORGAN :ORTISSUE DONATIGN BEEN CONSIDERED?
<br />0 YES NO
<br />26 DID TOBACCO IJSE CONTRIBUTE TO THE DEATH?
<br />:YES NO 13PROBABLY 0 UNKNOWN
<br />27. NAME, it AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />24d. TIME PRONOUNCED
<br />26b, WAS CONSENT GRAN '
<br />Not Applicable If 21Ia is NO ©YMis:
<br />2Sb. DATE FILED BY riots
<br />August 29, 2025
<br />4
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