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STATE OF NEBRASKA
<br />WHEN THIS >'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/22/2016
<br />LINCOLN NEEtRASKA
<br />201605238
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. 'COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Glen Eldon Bellew
<br />4. CITY YAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Greenwood County, Kansas
<br />7. SOCIAL SECURITY NUMBER
<br />515 -28 -0989
<br />8b FACILITY -NAME (If not Institution, give street and number)
<br />3116 North St. Paul Road
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE - STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3116 North St. Paul Road
<br />15a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, - Last, Suffix)
<br />William Christopher Bellew
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Blanche Bessie Brenton
<br />13: EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Ye No, or Un1.) Yes • 09/23/1952-09/22/1960
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal Q Other(Specify)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terrain& events such as cardiac arrest,
<br />respiratory aneat, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Unknown Natural Causes
<br />disease or condition resulting
<br />in death)
<br />APPROXIMATE INTERVAL s.
<br />onset to death
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially he Conditions, H : gi b)
<br />any, leading to the.causa 1(sted
<br />on tine a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE. c)
<br />!disease or of ury tttet initiated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />20. IFFEMALE:
<br />0 Not pregnant within past
<br />❑ Pregnant at time of death
<br />Net pregnant,'; but ptegnant within 42 days of death
<br />❑ Not pregnant, b ut pregnant43 days tot year before death
<br />❑ Unknlwm If pregnant within the past year.
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22d.::INJURY AT WORif?
<br />❑YES NO
<br />•
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />42 w 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />G W _1
<br />1 u 2
<br />v e, O 3d. To the best of my knowledge,. death occurred at the time, date and place
<br />8 G and due to the cause(s) stated. (Signature and Title)
<br />re W
<br />26a. HAS OR
<br />❑ YES
<br />25. DID TOBACCO USE ONTRIBUTE TO THE DEATH?
<br />EI YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />5a. AGE Last Birth
<br />{Yes)
<br />81
<br />day
<br />J 28a • EGlSTRAIS SIGNATURE .. 0,,,,,,,,,,,,.., iej
<br />8b UNDER 1 YEAR
<br />MOS.
<br />PAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand'Islantl
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Melinda Lee Benton
<br />14a. INFORMANT -NAME.
<br />Melinda Lee Bellew
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 COuld'not be determined
<br />16b, LICENSE NO.
<br />1454
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other(Specify)
<br />N OR TISSUE DONATION BEEN CONSIDERED?
<br />NO
<br />9f. ZIP CODE
<br />68801
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 1, 2016
<br />6. DATE OF BIRTH {MOir
<br />June 16, 1935
<br />Day, Yr.)
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />14b. RELATIONSHIP TO DECEDENT;
<br />Wife
<br />16c. DATE (Mo., Day,. Yr.)
<br />July 7, 2016
<br />17b. 2:fp Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES [g] NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH/:..
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />July 18, 2016
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />July 1,2016 01:07 PM
<br />12:00 PM
<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 the cause(s) stated. (Signature and Title)
<br />Kate Collins, Hall Deputy County Attorney
<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 />Kate Collins, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand .Island, Nebraska, 68802
<br />28b. DATE FILED BY REGISTRAR (NI Day, Yr.
<br />July 18, 2016
<br />
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