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<br />STATE OF NEBRAS A
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<br />WHEN MIS COPYCARRIES THE RAISED SEACOF STATE OF NEBBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE' COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND 7
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/31 /2026
<br />LINCOLN, NEBRASKA
<br />202605388
<br />202605389 Ass ARAH O E EC><ISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />} it
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDE (1'S-IIAME (First; Middle, Last, Suffix)
<br />Tom Ree CaFF#ts /,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bancroft, Nebraska
<br />7. SOCIAL scopNTY NUMBER
<br />508-50-2304
<br />6a. AGE Last Birthday
<br />(Yrs.)
<br />85.
<br />tab. FACILITY -NAME ie not Institution, gave street and number)
<br />Grand Island Regional Medical Center
<br />Ss. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />ea. RESIDENCE -STATE
<br />Nebtaska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />N
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />I1 ER/Outpatient
<br />CI DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursini(Home/LTC
<br />❑ Decedent's Home
<br />❑ Otther(Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />26'09938 > :
<br />3. DATE OF DEA'TII ((AA:, Day, Yr j
<br />July 16, 2026
<br />6. DATE OF BIRTH (Mo., Day, ;Yr.)
<br />June 1,0,1941
<br />❑ ffospiceFE FEARS,/
<br />11d. SIREETANDNUMBER
<br />336 RedwOod Rd
<br />9e. APT. NO.
<br />IR / ZIP CODE
<br />68803
<br />HOURS
<br />MINS.
<br />8p:1113 • E tot r U1..!TS
<br />10a. MARITAL. STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Masted, but Separated ❑widowed 0 Divorce 0 Unknown
<br />11. FATHERS -NAME (First;:;:; Middle, Last, Suffix)
<br />Wamie Rae Oaoiras
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes
<br />1B MI THODOFDISP(7Sric.
<br />❑ Buriat ❑ Donation
<br />®'Cremators 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />11'S. FUNERAL NAME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Horne, 2929 S. Loatlst Street, Grand Island, Nebraska
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Sonya J Selle
<br />14a. INFORMANT -NAME
<br />Sonya J Collins
<br />16a. FUNERAL DIRECTOR SIGNATURE'.
<br />Kelley D Sheridan
<br />12. MOTHER'S -NAME (First,
<br />Ellen B Mackey
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />1439
<br />Suffix) If wife, give madden nark*
<br />Middle, Maiden Surname)
<br />CITY/TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1s. PART I. Enter the chilli of event- -diseases, InjurieL or complkmpna�hef directy caused the deefh. DO NOT sorer instructions(
<br />even" such as cards c imam,
<br />ng the etiology. DO NOT ABBREVIATE. Enpr only One came on a: thw.. Add addition Ines M necessary.
<br />r.P$retcuyartgt,orvs"u' Iartibriastbnwithoutshows
<br />IMMEDIATE CAUSE:
<br />fiaLKEIATE4A09E1PiriXt s)cardiac arrest
<br />a s.MS W camltion:w�uhinp'`
<br />in death)
<br />peuendalb pet• cog4ttiorre, 8..::.
<br />Iirty tpggng to ths:canse tiywu
<br />on lingo ... ..
<br />Enter the IINDERI.Y8tO CAUSE
<br />(disease or injury that InMlated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)congestive heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />the even" mulinp indu" DUE TO, OR AS A CONSEQUENCE OF:
<br />tasT d) i
<br />18. PARTtI OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not minting In the underlying cause given In P
<br />obstructive sleep apnea, atrial fibrillation, osteoporosis, cirrhosis, chronic kidney disease
<br />20, IF FEMAt..i„: :.
<br />❑ NotPNMtlntsp8bldpast year-
<br />❑ Pifeatisilt at EON Of death:''
<br />ElNot pregnant, but pregnant wNhln 42 days of death
<br />ElNot emanate, but pregnant 43 dapto 1 year before death
<br />0 Mutant) if pregnant Within the pest year
<br />22a. DATOF INIIRY (Hfo,,Day, Yr.)
<br />22d. INJURY AT WORK?
<br />:]YES. CIAO
<br />21ia. MANNER OF DEATHmic Natural 0 Hoide
<br />❑ Accident ❑ Pending Investigation
<br />ElSuicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Orivetl >perator
<br />[3Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo :
<br />July 24, 2ag6
<br />STATE
<br />71s 21P C.0dI
<br />68804
<br />APPROXIMATE INTERVAL
<br />onset to dt att*
<br />1 Days
<br />ART I.
<br />19. WAS MEDIGAEEXAMINER"
<br />OR CORNER CONTACTED?
<br />❑YES u0..
<br />21e. WAS AN AUTOPSY PERFORMED?" :.
<br />❑ YES ®NO •
<br />21d. WERE AUTOPSY MOWS AVAILABLE.
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑uo
<br />22c. PLACE OF INJURY -At home, farm, Street, factory, office building, construction site, etc. ($pacify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />INJURYSTREE'ri NUMBER, APT.NO.
<br />235. DATE OF DEATH (Mo„ Day, Yr.)
<br />July 16 2026
<br />2Sb DATE SIGNED (Mo., Day, Yr.) 23e. TI E OF DEATH
<br />Jytii 23 2026 0621 AM
<br />30, To SNOW ofmy knouMdge, death occurred et the time, date and place
<br />.... and** to the cause(,) stated. (Signature and TMN)
<br />Isaac J. Berg, MD
<br />2 DID D 08ACcousE CONTRIBUTE TO THE DEATH?
<br />❑,;YES ® NO ©::PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNOED.O0Ab.
<br />24e.On **basis of examination and/or investigation, M my oplMan death OEcwiud at
<br />the tins, ate and place and due to the cause(s) stated. (Signature and MN)
<br />SSUE • • ANON BEEN CONSIDERED?
<br />El NO
<br />27. NAMEti;flTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, t29 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28t REGISTRAR SIGNATURE
<br />26b. WAS CONSENT GRANTED
<br />Not Appllcable If 26a Is NO 13.YE'S
<br />28b. DATE FILED BY REGISTRAR(Mp.,;Day, Yr)
<br />July 29, 2028
<br />
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