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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />CERTIFIES THE
<br />ON FILE WITH
<br />RECORDS OFFICE,
<br />DATE OF ISSUANCE
<br />7/12/2017
<br />LINCOLN, NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marsha Kay TrueII
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Shelby, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />482 -62 -2765
<br />Sb. FACILITY -NAME ((t not Institution, give street and number)
<br />CHI _Health! St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1740 South )malls Street
<br />2 15. METHOD OF DISPOSITION
<br />H ❑ Bunal ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Sequentially List conditions, if
<br />any, leading to Me Cause Ilsted
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />( disease dr injury inflated.;
<br />:the events teauitti g in death)
<br />IA57
<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 ptegn pregnant 43 days to 1 year before death
<br />0 it pregnant Within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. ! NJURY ATWORK?
<br />YES ,❑NO
<br />23a. DATE OF DEATH (Mo., Day, Vr.)
<br />JU V 6. 20171
<br />Isaac J. Berq :; MD
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, Out separated ❑ Widowed ® Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ernest Kiesel
<br />13. EVER IN U.S. ARMEO FORCES? Give dates of service if Yes.
<br />(Yes, No or Utk.) No
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease ■• c,ra•ion res. 'inn
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Encephalopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Cardiac Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)E Coli Sepsis
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />23b. DATE SIGNED (Mo., Day, Yr,) 23c. TIME OF DEATH
<br />July 7, 2017 12:25 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. )Signature and Title)
<br />201708675
<br />5a. AGE - Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.)
<br />68
<br />14a. INFORMANT - NAME
<br />Jonathan Hamilton Truell
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />25. DID TOBAGO() USE CONTRIBUTE TO THE DEATH?
<br />❑ YES {l NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. R EGISTRAR'S SIGNATURE
<br />MOS. 'DAYS
<br />9c. CITY OR TOWN
<br />Grand, Island
<br />STANLEY S. • OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />9e. APT. NO.
<br />b. LICENSE NO.
<br />Gibbon
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />CITY / TOWN
<br />STATE
<br />it3 ate
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient OTHER ❑ Nursing Home /LTC
<br />❑ ER1Outfatient ❑ Dededent's Home
<br />0 DOA ❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68803
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mildred Bailey
<br />CAUSE OF DEATHJSee instructions and examples)
<br />8. PART 1. Enter tit¢' chain Of eVehts -- diseases, injuries, or complications -that directly caused the death, DO NOT enter leonine' events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line,' Add additional lines R necessary.
<br />IMMEDIATE CAUSE:
<br />18. PART II. OTHER SIGNIFICAt4T CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />❑. Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 6, 2017
<br />6. DATE OF BIRTH (Mod, Day, Yr
<br />April 11, 1949
<br />10b. NAME OF, SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Son
<br />❑ YES El NO
<br />24b. TIME OF DEATH
<br />28b. DATE FILED BY REGISTRAR (M
<br />July 10, 2017
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />16c. DATE (Mo., Day, Yr.)
<br />July 7, 2017
<br />STATE
<br />ebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE I
<br />onset to death
<br />10 Days
<br />onset t0 ;Ilea
<br />10 Days
<br />onset to death
<br />10 Days
<br />onset tt) d
<br />10 Days
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES X�INO
<br />21c. WAS AN AUTOPSY PERFORMED ? - -:
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH'.
<br />❑ YES L-1 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<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 />ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TINE 1RONOu) ED DEAD
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<br />26a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED?
<br />26b. WAS CONSENT GRANTE
<br />Not Applicable if 28a is NO ❑ YES ❑ NO
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