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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 4/25/2017 LINCOLN, NEBRASKA IS 0.. U' W e IS tit: z LL at w 0 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Marian Kay Dennis 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Beerier, Nebraska 7. SOCIAL SECURITY NUMBER 506 -40- 4402: 8*a, FACILITY -NAME (If not Institution, give street and number) Grand Island; Lakeview Care & Rehabilitation Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a• RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1404 West 3rd Street 105.. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ['M arried, but.separated ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First, Middle, Last, Suffix) Lorin Martin 13.EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) No Tracy Carpenter 15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE E Burial 0 Donation ❑ Cremation ❑Entombment ❑ Removal .,❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska i >ea >o conomon Sequentially Usf con lhions, •tf any, iea • • rrg to the •cause hated on linea. nter the UNDERLYING CAUSE s ense. O/ iiujury that initrdte the e' Ants resuitin9.lit death) LAST 0. IF FEMALE:' ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but p reg n ant wit 42 days of tleath © Not pregnant, but p ant regnithinant 4 the days to 1 year before death ❑ Unknown if pregn w past year 22a. DATE OF INJURY (Mo., Day, Yr.) CI. INJURY AT WORK ?' JYES ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. BA-re OF Apr)) 13 2017 23b. DATE SIGNED (Mo., Day, Yr.) Aurli 13, 2017 3u. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Sa ra GraVbiil,iMD ATH (Mo., Day, Yr.) /(4001", Miss Moat% 0 X G rr img STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 2e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH C1:35 201705725 5a. AGE = Last Kilt :Jay (Yrs.) 81 Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigatict ❑ Suicide ❑ Could not be delete: ned CITY /TOWN b UNDER 1 YEAR MOS. :c CITY OR TOWN I Grand Island DAYS 8a. PLACE OF DEATH HOSPr'AL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9e. APT. NO. STANLEY S.mCOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Female 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 16b, LICENSE NO. 1323 CITY I TOWN Grand Island 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE i BEEN CONSIDERED? E YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E ,IO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sara Graybill MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 fti MINS. 9f. ZIP CODE 68801 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Warren G Dennis 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Emma Hoefs CAUSE OF DEATH See instructions and examples) t a. PART l. Enter the them of events- - diseases, injuries, or complications -that directly caused the death. DO NIT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter onli one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Lung Cancer STATE 24a. DATE SIGNED (Mo., Day, Yr.) August 17, 19 ❑ YES ❑ NO 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.l) 24d. TIME PRONOuri CEr3 D �1 ilt 22c. PLACE OF INJURY - it home, farm, street, factory, office building, construction site, etc. (Specify) 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 28b. DATE FILED BY REGISTRAR (MQ,Day, Yr.) April 24, 2017 3. DATE OF DEATH (Mo., Day, Yr.) April 13, 2017 16c. DATE (Mo., Day, Yr.) April 18, 2017 6. DATE OF BIRTH (Mo. Day, Yr) onset to deatil onset to death 21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator ❑ YES ®NO ❑ Passenger 0 Pedestrian Other' (Specify) 5 OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 9g. INSIDE CITY LIMITS E YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter STATE Nebraska:' 17b. Zip: Code 68801 APPROXIMATE: :INTERVAL onset to death 2 Months 2Ba REGISTRAf'S SIGNATURE ZIP CODE 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not ,vaulting in the underlying cause given in PART I. 1 19. WAS MEDICAL EXAMINER Pulrri 3nary Embolus, Subdural Hematoma OR CORONER CONTACTED? D' +I NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? Is 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO