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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMANiSERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBPA K Air Wt'r HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1 `
<br />DATE OF ISSUANCE
<br />03/19/201
<br />LINCOLN, NEB
<br />4 . AfIf2EY`S. COOP.E.R
<br />,issiSTA ,, ATE Rq'J
<br />ERTMIF
<br />NEBRASKA
<br />20190'7052
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEfVI� . �'✓�, yr4
<br />�. F�..eRAs
<br />CERTIFICATE OF DEATH
<br />•�% .r1401115
<br />4*
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marlene Cecelia Roush
<br />2. SEX h 1 '• , j
<br />Female 1‘., ,
<br />C TE QPjj[]gARl (MO., Day, Yr.)
<br />arch j, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />' 8: DAtAF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs•)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 4, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />508-28-9537
<br />8a. PLACE OF DEATH
<br />HOSi52AI. 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Spey)
<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 />8t,. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />225 Midaro Dr.
<br />9e. APT. NO.
<br />W. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Sufnx) If wife, give maiden name
<br />Donald Roush
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />George Leschinsky
<br />12. MOTHERS -NAME (First, Middle, Malden Surname)
<br />Edna Nielsen
<br />13. EVER IN U.S. ARMED FORCES? Glee dates of service H Yes.
<br />(Yes, No, or Un k.) No
<br />14a. INFORMANT -NAME
<br />Dana Jelinek
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSrON
<br />❑ Burial ® Donation
<br />19a. EMBALMER -SIGNATURE
<br />Paul Becker
<br />18b. LICENSE NO.
<br />1085
<br />18c. DATE (Mo., Day, Yr.)
<br />March 7, 2014
<br />❑ Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Nebraska Anatomical Board Omaha Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />M Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />1A PART I. Enter the imam of events -diseases, Mutes, or compllaaona4 hat directly caused the death. DO NOT enter terminal want, such as cardiac wrest,
<br />APPROXIMATE INTERVAL
<br />naphalry arrest, or ventricular fibrillation without showing tit otology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ona if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Dementia
<br />disease or condition resulting
<br />onset to death
<br />4 Years
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Seeuentiay list conditions. If b)
<br />any, leading to the cause listed
<br />onset to death
<br />on use a' DUE TO, OR AS A CONSEQUENCE OF: •
<br />Ester be UNDERLYING CAUSE C)
<br />(disease or Injury that Irrigated
<br />onset to death
<br />the assets resulting le darn) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®No
<br />20. IF FEMALE:
<br />❑ Not pregnant within put year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 PedaaMan
<br />0 Other (Specify) i
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY•M home,
<br />farm, street, factory, otfleelbuilding,
<br />construction site, We. (Spselfy)
<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 />S
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March7,2014
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 7, 2014
<br />23e. TIME OF DEATH
<br />03:22 AM
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />CCC3J
<br />To 1st bit of my Iwowlsdpe, death nature a al the time, dais and pba
<br />E and due to the cause(*) stated. (Signature and Title)
<br />David R. Colan, MD
<br />24e. On the basis of examination and/or Investigation, In ny opinion death occurred at
<br />the time, dab and place and dm to the cause(*) stated. (Signature and TIM)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I28a. HAS ORGAN ORISSUE ,
<br />YES ® NO 0 PROBABLY 0 UNKNOWN I 0 YES •
<br />TION BEEN CONSIDERED?
<br />AN
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES 0 NO
<br />27. TITLE AND ADDRESS OF CERTIFIER (Type or Pytj
<br />David R. Colan, MD, 729 North Custer Avenue Grand Island, Nebraska,• :1803
<br />28a. REGISTRAR'S SIGNATURE
<br />/'s /
<br />2Sbr DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 10, 2014
<br />
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