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<br />1STATE OF NEBRASKA-- ,:;1:;,:;;;,;...
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<br />WNW MIS CORY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />i
<br />t
<br />TE OF ISSUANCE'
<br />11 /18/2025
<br />LINf^QLN, NEBRASKA
<br />202604252 jootil goitAzakt,
<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 /><D Dr;NT'S killtp.(FIrI Muddls, Last, Suffix)
<br />Th9!1'. kill 'Aills
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kirnb81; 'Nebraska < ?' .
<br />'t,socim,Agpootre Pa ER
<br />50554 341 `
<br />tie AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />Ob. FACILITY -NAME (M not institution, give street and number)
<br />CrflFf6r Gardens
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />tie. UNDER 1 DAY
<br />M08...
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />❑ ER/Outpatient
<br />a OQA.
<br />op. CPTy OR ltw$OF pakot (include Zip Code)
<br />Grand island' 68803
<br />9a. RESIDENCE -STATE
<br />NeDi i$tca r ;<: >
<br />ail TPOIET 340 NUN)88R , i
<br />'' ! t 1117th:etteeti::
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />Q IN#rN. d, bu.,.t., .Ptrcat d ❑ Widowed 0 Divorced ❑ Unknown
<br />11 FATNEAI'$.NAME •tfbet:::: Middle, Last, Suffix)
<br />Thee done 04130.7tent
<br />13. EVER(N U.S. ARMED FORDES9
<br />(Yes, No, drunk.) NQ -
<br />45J4ETNOD.OF. M8POOFI IN -�
<br />IAl *canal Donation
<br />0 erstiottown Entannbment
<br />❑ Removal 0 Other (Specify)
<br />29. t UNEita. H?. IAE BARE *ND MAIUNG ADDRESS (Street, City or Town, Stets)
<br />Ail Faiths Funeral Hogue, 2929 S. Locust Street, Grand Island, Nebraska
<br />9c. CITY OR TOWN
<br />Grand is)and
<br />HOURS
<br />MINS.
<br />3. DATE OF DEA
<br />November,
<br />S. DATE OF BIM* (MO., Day, Yr.)
<br />February
<br />OTHER ❑ Nursing Homs/LTC
<br />❑ Decedent's Home
<br />® Other ISP•cKyWSSISTEI t.VH
<br />lid. COUNTY OF DEATH
<br />Hall
<br />Oa. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Gary Geo
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, give maiden trams.
<br />Ie Purvis .
<br />12. MOTHER'S -NAME (First, Middle,
<br />Elaine Wiese
<br />14a. INFORMANT -NAME
<br />Gary George Purvis
<br />19a. F3`ERAL DIRECTOR SIGNATURE"
<br />Laurie D. Sheffield
<br />tbb. LICENSE NO.
<br />1397
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />•dl...a.>ott+rialtNhtw.uitatbi
<br />la death)
<br />: .4*. p i tat.
<br />4.:. ':„9rtertlwu11DERLWifJtaCAU e
<br />Is (daisies or Injury that initiated
<br />IN everts resWthrg M dsalh) N
<br />i,AST
<br />Malden Sumamel-
<br />CAUSE OF DEATH (See instructions and eecamolee)
<br />1t. PART'. Sh11tn4 chair Or Ivat diseases, Nunes, or complkalbns4hat directly caused the death. DO NOT enter tennlnal *vents such as cardiac arrest,
<br />tsalgret*ty swat, or ventScofarflb4Leitlen without showing the etiology. DO NOT ASBREYIATE. Inter aft ..prw cause on .a Ma. Add additional lines if necessary.
<br />•>;:;IMMEDIATE CAUSE:
<br />>e) Cerebral Atherosclerosis with -Vascular Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Rlr(NIo,il aria::.;: b)
<br />:.YirflUus 0110
<br />>DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />111. PArE'F:14 0111.. 134IpiCANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension, Coronary Artery Disease \
<br />agt:+lrtl I�MALE
<br />o N01Prepae« WNan *IOt year
<br />'p i spa 'or o
<br />❑ Not portent, but piegnam within 42 days or death
<br />..❑ Nat ,Pregnant,,but preptMnt 43 days to 1 year before death
<br />IAiNnewn it prep *Or t4PStin t1:N Pest Veer
<br />DATi otin4A1 ((do.; pay, Yr.)
<br />22d.INJURY`AT 9
<br />DYES t0
<br />21a. MANNER OF DEATH
<br />❑ Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DNv*rlOperator
<br />'❑ Plassnasr
<br />❑ Pedeshlan
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse '":,..
<br />19c. DATE (Mo,,
<br />- November
<br />STATE
<br />onset to death
<br />efleet t0
<br />19. WASHROOM.
<br />OR CORONER CONTACTED?
<br />❑ 'as :.:::r1;..
<br />21c. WAS ANAUTOP*Yf l
<br />❑ YES 61 Nei
<br />21d. WERE AUTOPSYFINOINe$ AVAILAOLI
<br />TO COMPLETE CAVES 0I. DSATHI .
<br />YES ❑ OR
<br />>::.:.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />*•22r LOCATION Of INJURY .SITREET a NUMBER, APT.NO. CITY/TOWN
<br />Pl .
<br />STATE
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />November 3, 20255
<br />230 DATE $*GNEO (Mo., Day, Yr.)
<br />N9v mb9r 4 0 5
<br />..ilit,.,.,.I0410 uut ol'my , death occurred at the time, date and place
<br />•'�:.;; and OW to thrV'eauea(s) stated. (Signature and MN)
<br />Gary L Settle, MD
<br />23c. TIME OF DEATH
<br />12:20 PM
<br />M AIR CA t ..ON1' UBUTE TO THE DEATH?
<br />4tOBABLY UNKNOWN
<br />lrl. NANICI13 11%A b A , Qy SS OF CERTIFIER (Type or Print
<br />Gard/ L Settle, MD, 416 N Diers Ave, Grand Island, Nebraska, 68803
<br />REGISTRARS.S(GNAnets C>
<br />1 SFr
<br />a
<br />2Aa. DATE SIGNED (Mo., Day, Yr.)
<br />24c.:PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. T1ME of DEATH
<br />24d. T011E
<br />2M. An the aile of examination and/or Investigation, In my upinkN
<br />the time, date and place and due to the causehli Motet ISIIPIStum WO
<br />26a. HAS ORGAN OR TISSUE DONA-HON BEEN CONSIDERED?
<br />0 YES 1( r
<br />26b. WAS CONSENT
<br />Not Applicable R 211a Is,NO
<br />2Eb. DAME FILED SY AlbtEE f!
<br />November 12, 2025
<br />CIT
<br />9b.000NTY
<br />Hall
<br />
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