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<br />STATE OF NEBRASKA
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<br />WHEN MIS 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 7
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />20.2605388`
<br />202605389
<br />DATE OF ISSUANiE
<br />7/31/2026
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HIJMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE b
<br />OF DE
<br />( Dgogos rti. NAME ; (Foi Mlaldle, Last, Suffix)
<br />Toff Ree ' Col Ins z.
<br />2. SEX
<br />Male
<br />:26 O99.3
<br />3. DATE OF DEATH {Mg„ tley; Yr;)..
<br />July 16, 2026.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 19,1941.
<br />Q 1tespfee Fa &lily
<br />3
<br />1
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bancroft, Nebraska
<br />SO:GIALBECUR*TY:.NUMBER
<br />508-50-2304
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />6b. FACIUTY-NAME (y not Institution, give street and number)
<br />Grand island Regional Medical Center
<br />8c CITY OR TOy4Ht OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />85
<br />Sb. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® ER/Outpatient
<br />0 DOA
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing/Home/LTC
<br />❑ Decedent's Harm
<br />❑ 6the►(SpscHY)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />::Nebraska
<br />ed. STREETANDNUMBER
<br />336 Redwood. Rd:: -
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH RI Married ❑ Never Married
<br />;,;,.;❑ Married, but.septtreted ❑ Widowed 0 Divorceii 0 Unknown
<br />11. FATHER'S -NAME (First;;: Middle, Last, Suffix)
<br />Warne ' Rae Collins
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or link.) Yes
<br />9c. CITY OR TOWN
<br />Grand Island
<br />tle. APT. NO.
<br />9(. ZIP CODE
<br />68803
<br />9p. 0.0l'!B chTY Ostt :
<br />a
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sonya J Selle
<br />14a. INFORMANT -NAME
<br />Sonya J Collins
<br />16 METHOD OFCtSt*O$ITtd11
<br />Q Buri*t <Q bonatla
<br />® Crellpttion:Q Entombment
<br />❑ Removal 0 Other (Specify)
<br />12a FUNERAi NN AME AME ("icily)
<br />MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locist Street, Grand Island, Nebraska
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ellen B Mackey
<br />16b. LICENSE NO.
<br />1439
<br />CITY 1 TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal everts such as card) c arrest,
<br />npplratpty arrpi, orverr%icular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lbw. Add addkbnaFinu if necessary.
<br />IMMEDIATE CAUSE:
<br />a,NdEFNATg Osi1$ (Pni '"Bl cardiac arrest
<br />dleaaaf atmdlwgio i:muMn9
<br />N death) DUE TO, OR AS A CONSEQUENCE OF:
<br />gewtentially Nstcondition& ..> b)congestive heart failure
<br />row, leading* the cause lust!:
<br />on lime.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eraer the UNDERL1Wiff CAUSE C)
<br />Misesee or injury that IMtie1W
<br />the avant. rssuahp ki death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />I6. PARTSIGHIFICANT CONDITIONS -Conditions contributing to the death but not resulting. In the underlying cause given In PART I.
<br />obstructive sleep apnea, atrial fibrillation, osteoporosis, cirrhosis, chronic kidney disease
<br />2Ik IF FEMAt,E
<br />Q Not pr .0143 peat yse,
<br />❑ htignwitatt(a ordesgl
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but decadent 43 days to 1 year before oath
<br />Q Unknown N IROSpert i1Nd!n:1M pat year
<br />32a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />•3YES DNo
<br />221L;4r'CA11
<br />21ta. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide Q Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Q- Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse ..
<br />16c. DATE (Mc(psailYr.) .
<br />July 24, 2029
<br />STATE
<br />.-.Nebraska:::.;>::
<br />6880'T
<br />APPROXIMATE INTERVAL
<br />onset to flaNil)t
<br />1 Days
<br />onset to death
<br />9 Yel*rs
<br />onset to .dtgdir'
<br />19. WAS MEDICAL EXAMINER`
<br />OR CORONER CONTACTED?
<br />❑ YEs :::RI NO
<br />21c. WAS AN AUTOPSY PERFORMED?,:,;;
<br />Q vas ®NO ;`
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF, DEATH?
<br />❑ YES ❑ 140
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sib, etc..)
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />OP INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE p CODE
<br />1
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />July 16, 2026
<br />230DATE SIGNED (Mo., Day, Yr.) 23c. TIRE OF DEATH
<br />Julie23 2Q26` 021 AM
<br />sso. To (*: beat oTnty knowtedge, death occurred at the time, date and place
<br />and die to'tirs'uuse(s) sated. (signature and Tim)
<br />Isaac J. Berg, MD
<br />2 tND OBACCO:U8E CONTRIBUTE TO THE DEATH?
<br />[ ;:YES I P40 Q:::PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCEt3£'fEAD l
<br />Ile, On the. basis of examination and/or investigation, In my opinion daalh eeet4A/ at
<br />the time, ate and place end due to the taunts) stated. N i9atun and TNN)
<br />TISSUE DONATION BEEN CONSIDERED?
<br />El NO
<br />37. NAME TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, t29 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />SISAL REGISTRAR'$ SIGNATURE
<br />28b. WAS CONSENT t RANTEt3i
<br />Not Applicable If 28a Is NO
<br />28b. DATE FILED BY REGISTRAR BO, D;sry, Yr )
<br />July 29, 2026
<br />
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