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STATE OF NEBRASKA
<br />201601680
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT,(j.A NL9 NtiUJN4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAM) ,E'ARTM &A1T HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR - VITAL RECORRCS
<br />DATE OF ISSUANCE
<br />01/30/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICOS
<br />CERTIFICATE OF DEATH
<br />''STANLEY S D OPER t
<br />ISTTS,'rA, F EGISARF
<br />;DEPARTII('ll AIT'OF H MTH•AND ;`
<br />BOMAN SERVICES l ;
<br />P;
<br />15 00453
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />Marlene Mae Byerly
<br />2. SEX ' .
<br />Female
<br />3. DATE'OF „DtATH (Mo., Day, Yr.)
<br />January 22, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rural Hall County, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />78
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 4, 1937
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -44 -3370
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4838 St. Paul Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Virgil Franklin Byerly
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Elmer Kay
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Lillie Falldorf
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Virgil Franklin Byerly
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER- SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />January 27, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the chain of events• -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Acute Hypoxemic Respiratory Failure Hours
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b) Pulmonary Edema 1 Hours
<br />any, leading to the cause listed I
<br />1
<br />on line e. DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE C) Acute On Chronic Diastolic Heart Failure 1
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) I
<br />1
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Neuroendocrine Tumor Of Liver, Endometrial Carcinoma, Diabetes, Hypertension, Atrial Fibrillation, Nephrolithiasis,
<br />Hypothyroidism, History Of Pulmonary Embolus
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />.1' W
<br />ea r
<br />I u E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 22, 2015
<br />Z
<br />' u g
<br />i I r
<br />o o..4 c
<br />u W z
<br />A 2 p
<br />I- s
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 26, 2015
<br />23c. TIME OF DEATH
<br />I 11:13 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />g o and due to the cause(s) stated (Signature and Title)
<br />Z Jay C. Anderson, MD
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to INC cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ID NO ❑ PROBABLY ❑ UNKNOWN I
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />SSUE DONATION BEEN CONSIDERED?
<br />17 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />128a. REGISTRAR'S SIGNATURE A - p � V
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 27, 2015
<br />STATE OF NEBRASKA
<br />201601680
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT,(j.A NL9 NtiUJN4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAM) ,E'ARTM &A1T HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR - VITAL RECORRCS
<br />DATE OF ISSUANCE
<br />01/30/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICOS
<br />CERTIFICATE OF DEATH
<br />''STANLEY S D OPER t
<br />ISTTS,'rA, F EGISARF
<br />;DEPARTII('ll AIT'OF H MTH•AND ;`
<br />BOMAN SERVICES l ;
<br />P;
<br />15 00453
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