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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH aIND MUM�{N �ERVtCES, IT GERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP.A��T,M�NT'Q�' NEAC7"H AiVD
<br />' HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT�C.R�'CQRl3�" " i ;^ ,��'. :,,;'
<br />, � � �`;
<br />DATE OF ISSUANCE ,��/�� �� y '��, I `� l i�
<br />� STAl1(CEY'�5 Cf�G�R�R � � '^
<br />' 10/29/2010 ca As��'F�nrT �r,a�� �a�G,�s�raa� � ; � . °
<br />�0��1059$5 o�P������Q�����H;�N �a
<br />LINCOLN, NEBRASKA H(.fM SEftWICEa� � .� �
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<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERYICES� :�� � ��'" �" �:'� O O3O7B
<br />CERTIFICATE OF DEATH � �`�'.� � � �� ,
<br />1. DECEDENTS-NAME (First, Middle, Last, Suftix) 2. SIX y : '�,'3.r DATE�,OF OEATM.(Mo., Day, Yr.)
<br />Raymond Thomas Stryker Male �` ',- Qctobec 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Blrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DA7E OF BIRTH (Mo., Day, Yr.)
<br />(�'�•) MOS. DAYS HOURS MINS.
<br />Grand Island, Nebraska 71 July 31, 1939
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506-50-7502 OH SPITAL � Inpatierrt OTHER ❑ Nursing HomelLTC � Hoepice Faclilty
<br />8b; FACILITY•NAME pT not Institutlon, give street and number) � ER/OutpaUent � DecedeM's Home
<br />_2301 North Lafayette _ .- - -- - = - -=- - _ - - _ -ag _. -- - -�e'-�spe�K�'-�-- --- -
<br />_ _ _ -�-
<br />Bci CITY OR TOWN OF DEATH (I�lude Zip Code) 8d. COUN7Y OF DEATH
<br />Grand Island 68801 Hall
<br />8a. RESIDENCE 9b. COUN7Y 9e. CITY OR TOWN
<br />�Nebraska Hall Grand (sland
<br />d: STREET AND NUMBER e. APT. NO. 8L ZIP CODE 9g, INSIDE CITY LIMIT
<br />2301 North Lafayette 68801 � rES ❑ No
<br />Oa. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 10b. NAME OF SPOUSE (FUst, AAtddle, Last, SuHix) N wHe, gWe maiden name
<br />p Marrled, but separated ❑ Wldowed ❑ Dlvorced ❑ Unknow� Lila Jean Sorahan
<br />1: FATHER'S-NAME (First, Middle, Last, Suffl�c) 12. MOTHER'S•NAME (Firet, Middle, Malden Sumame)
<br />Raymond Stryker I Phyllis Brensinger
<br />� EVER IN U.S. ARMED FORCES? G(ve dates pf aervice H Yes. 14a. INFORMANT-NAME
<br />�res, No, or unk.� No Lila Jean Stryker
<br />. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE
<br />�] sunai ❑ oonation Not Embalmed
<br />� CremaUon ❑ Entombmerrt �gd. CEMEfERY, CREMATORY OR OTHER LOCATION
<br />� Removal ❑ Other (Specify)
<br />Central Nebraska Crema�on SeMces
<br />a• FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />CITY/ TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />16e. DATE {Mo., Oay, Yr.)
<br />Oetober 29, 2010
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />1B. PART I. E�rter the chain of eveMS-�dlaeases, InJuHea, or compllCatlona•that direcqy caused the death. DO NOT e�rter term(nal eveirte such as cardlac errest, = ApPROXIMATE INTERVAL
<br />respiratory artesy or venMcular NbrUlatlon without showing the atlology. DO N0T ABBREVIATE EMer only one cause on�a IOre. Add eddldonal Iinea if neceasary. �
<br />IMdIEDIATE CAUSE: ; o�et to death
<br />i�ir�owrECause�� a)Throat Cancer - Squamous Cell Carcinoma 6 7 Years
<br />_.._ _ _ a+�easeo.mnettion-resmn,t0 - - . .. .. . . . . . . � .� . . - - --
<br />. - _- -. . . !_--. _ .-- -- -. . _ - - --- -�
<br />�� �� DUE TO, OR AS A CONSEQUENCE OR ,
<br />Se9uentialy ��at conamo�. �t b)
<br />airy. leadine to the cause Iisted
<br />��' ��� e � D TO, OR AS A CONSEQUENCE OF:
<br />E�er ttre UNDERLYIN6 CAUSE �l
<br />(dl�ease or InJury that Initiated � �
<br />� a�"�'�"�" �" �� DUE TO, OR A$ A CONSEQUENCE OF:
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<br />o�et to death
<br />9.; pART tl. OTHER SIGNIFICANT CONDITIONS�Condklons contribuUng to the death but not resulting fn tha underiying cause gNen In PART I. 19. WAS MEDICAL IXAMINER
<br />D3abetes OR CORONER CONTACTED?
<br />� YES ❑ NO
<br />1. !F FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� NM pregn&rrtwlGUn peatyear � Nature� � HoMclde � DAve70peratpr �
<br />[] are¢naMSenme otaeen, p n�aaaM � Vendln8lmestlBetlOn ❑��eer ❑ ves � nto
<br />� Not pregna�rt, but pregnant within 42 days ot death � pedeatrian 21d. WERE AUTOPSY FINDINGS AVAILA
<br />� Suicide � Could nM be tleterminetl TO COMPLETE CAUSE OF DEATH7
<br />Not pregnant, but pregnant 49 days to 1 year before death � Oqier (Speciry)
<br />� Unlmown H pregnaM wNhM the past year ❑ YES ❑ NO
<br />ta. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22a PLACE OF INJURY•At homa, farm, streat, factary, office bullding, co�trucUon slte, etc. (Spec(fy)
<br />INJURY AT WORK? I22e. DESCWBE HOW INJURY �
<br />� YES � NO
<br />LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a DATE_SIGNED.�Mp., Day, Yr.) � 24b. TIME OF DEATH
<br />S�� October 28, 2010 Approx. 12:30 AM
<br />� 23b. DATE 3IGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PRONOUNCEq DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />z E a<�' OCtOber 27, 2010 10:50 AM
<br />� . To the bast ot my Imowiedpe, Geath oaurred at tire tlme. date end place $� � 24e. On the basis ot exeminatlon and/or Imeetlgadon. In my opinion tleafh oaurted et
<br />� and due to the cau�(e) slated. (Signatura and TIUe) �& the tlme, date and place and tlue M fhe cause(s) etated. (S18nature and TIGe)
<br />� '' g a Sarah Carstensen, Hall Deputy County Attomey
<br />ID TpBACCO U9E CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
<br />, � YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO NotApplicable K26a Is NO ❑ YES ❑ NO
<br />AME, TITLE D ADDRESS OF C IFIER (P YSICIAN, SIC ASSIS ORO R I R A RNE1� ype or Print)
<br />�Sarah Carstensen, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Istand, Nebraska, 68802
<br />iG REGlSTRAR'S SIGNATURE��� �- 28b. OATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />October 28, 2010
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