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<br />WHEN THSS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELbW 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 />NOM
<br />1s
<br />a
<br />a
<br />1
<br />DATE OFISSUANCE
<br />8/27/2026 \
<br />LINCOLN, NEBRASKA
<br />202605587
<br />z
<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 />1. DECEDENTSNAME (First,:, Middle, Last, Suffix)
<br />Raymond Joseph O'Connor
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sioux City, lows
<br />2„ SOCIAL SECURITY`. NUMBER
<br />480-54 9303
<br />6a. AGE • Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />611 Fleetwood Road
<br />8c cnv OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />ed. STREET AND: NUMBER
<br />611 Fleetwood Road
<br />i
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />1f. FATHER'S -NAME (Prat, misses,
<br />Vincent R O'Connor
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes
<br />1L METHOD OF DISPOSITION
<br />fo Burial E;:3 Donation;
<br />❑ eradiation Q Entombment
<br />❑ Removal 0 Other (SMGN)
<br />Last, Suffix)
<br />79
<br />. UNDER 1 YEAR
<br />MOS.
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />DAYS
<br />8a. PLACE OF DEATH -
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />D
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />HOURS
<br />MINS.
<br />:26�1
<br />3. DATE OF DEAT#t tMo:,
<br />August 17, 202E'.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 27, 1947
<br />OTHER ❑ Nursing Home/LTC_
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑ idapics Fecfifty
<br />SS INSIDE cry Limas
<br />Wm o:>:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jennifer Schmidt
<br />14a. INFORMANT -NAME
<br />Jennifer O'Connor
<br />18a. FUNERAL DIRECTOR SIGNATURE 7
<br />Patricia R, Curran
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Angela C Duffy
<br />'Mb.'LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />111. PART 1. Enter the cMln of events- dowses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardl.c arrest,
<br />reaphgory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE *alias Tine a) Leptomeningeal disease
<br />Ansa or week* resulting /
<br />M dean( DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially lineendkiona,lr b)Metastatic melanoma to liver, adrenal gland
<br />any. leaalnti 03 the Cuss listen
<br />on Ww'R.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the MORRLWIGCAuse cl Cutaneous melanoma of left shoulder
<br />(disease or Injury that Initiated
<br />the events moulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS•CondItiona contributing to the death but not resulting in the underlying cause given in PART I.
<br />29)IF FEMALE: <:'<
<br />❑ Nat pregnant RMrin pitet ye*r
<br />❑ Pnpnaat W* rit Of aeaW
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />U$ nown if pfien*M$t hhf th. pest year
<br />22a.
<br />TE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other awcify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Dsy; Xs.)
<br />August21:2026
<br />STATE
<br />Nebraska
<br />17b FJp Dade
<br />68801`
<br />r
<br />APPROXIMATE INTERVAL I
<br />onset todttath
<br />4 Weeks
<br />onset to death
<br />1.5 Years
<br />onset to death<
<br />2 Years
<br />onset to dntla
<br />19. WAS MEDICAiEXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ...® NO
<br />21c.LW, WAS AN AUTOPSY ISERFQRMED?
<br />LJ YES ®NO
<br />21d. WERE AUTOPSY FINDINNGqS8 AVAILABLE
<br />TO COMPLETE CAUSE OF 'DEATH?
<br />❑TES ❑NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. Opacity)
<br />22d. INJURY AT WORK?
<br />OYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN
<br />i
<br />STATE
<br />tTiP'CODE . ,
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 17, 2026
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 25.2026 .
<br />23c. TIME OF DEATH
<br />01:35 PM
<br />2313. Tb &e best orrery kdoaAedge, death occurred at are time, date and place
<br />•-- and daa to thecauae(s) stated. (Signature and Me)
<br />Sarah L Creamer, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />2Ac. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCE DEAD
<br />24s On the beats of examination and/or hivsatgatbn, in my opinion death occurred at
<br />the time, date and place and Ow to the cauaa(s) stated. (signit*ss and Tkla)
<br />Dlp TGBACCO'use CONTRIBUTE TO THE DEATH?
<br />YES NO®PROBABLY 0 UNKNOWN
<br />21. NME, TITLE AND AGDRE$S OF CERTIFIER (Type or Print
<br />Sarah L Creamer, MD, 2730 W Faidely‘e,ve, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE a
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28b. WAS CONSENT `RANTEbe
<br />Not Apptksbls If 26a is NO 0 YES>
<br />28b. DATE FILED BY REGISTRAR (MO Day, Yr #
<br />August 26, 2026
<br />
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