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<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 DEPOSITARY FOR VITAL RECORDS
<br />DATE OF ISSUANCEp RUSSELL FOSLER
<br />12/19/2019 2 0 2 0 0 0 0 8 9 ASSISTANT STATE REGISTRAR
<br />vv DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Billy Duane Jussel
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 11, 2019
<br />4. CITY ANA STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wauneta, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />ea
<br />. 507-36-9247
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mg, NY.
<br />December 10; 1934
<br />p 8b. FACILITY -NAME (If not institution, give street and number)
<br />2109 West 15th Street
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand. Island 68803
<br />1
<br />v
<br />a
<br />m
<br />3
<br />A
<br />3
<br />0
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2109 West 15th Street
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />aaoA
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedents Home
<br />0 ;)tier (Specify(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY 13MITS
<br />N YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (Vint, Middle, Last, Suffix)
<br />Francis Jussel
<br />10b. NAME OF SPOUSE (Fina, , Middle, Last, Suffix) B wife, give maiden name.
<br />Betty Jane Wilcox
<br />12. MOTHER'S -NAME (First,
<br />Berdeane Willsey
<br />Middle, Maiden Sumame)
<br />13. EVER IN U.S.<ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Yes ';06/1953-06/1956
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />['Removal 0 other{Specify)
<br />14a. INFORMANT -NAME.
<br />Betty Jane Jussel
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />18b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT..
<br />Spouse
<br />16c. DATE (Mo., On Yr.)
<br />December 16,2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />0
<br />m
<br />g11 PART 1. Enter Me Oak events --diseases, inhales, or compllcations-eut directly caused the death. DO NOT enterterminal 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />M
<br />IMMEDIATE CAUSE (Final
<br />:Le.La C. ...... R$ui•"
<br />in death)
<br />Sequentially list colditidne, H
<br />any, leading to the cause tested
<br />on line a
<br />Einer the UNDERLYING CAUSE
<br />10155550 Or injury diet initiated::::
<br />the events rasufIng m (leach)
<br />LAST::
<br />CAUSE OF DEATH (See instructions and examples)
<br />a) Hypertensive Heart Disease With CHF
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Coronary Artery Disease
<br />STATE
<br />Nebraska
<br />171),21p Code
<br />68801
<br />APP ROXIMATEI NTERVAL
<br />onset to death
<br />Years
<br />onset to dead
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART 11. OTHER SIGNIFICANTCONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Dementia, Sip, Aortic Valve Repair, Paroxysmal Atrial Fibrillation, Probable Myesthenia Gravis Affecting Eyes, H/O Bladder And
<br />Lung Cancer, COPD, Depression, Peripheral Vascular Disease With AAA Repair And Right Internal Carotid Artery Aneur
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnantat time a death
<br />0 hoof paegnant,:hut pregnant within 42 days a death
<br />❑ Nat pregnant,ANd pregnant 43 days to 1 year before death
<br />❑ tlnkrrovrn t pregnant wftdn the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. -INJURY AT WORK?
<br />❑YES ONO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2111. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other (SPwwcity)
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAI(,ABLE
<br />TO COMPLETE CAUSE f3F DEATH?
<br />❑ YES ❑ NO
<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 />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />17 W December 11, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 13. 2019 07:06 AM
<br />g O 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />w
<br />Kimberly A. Nickels, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<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 />26a. HAS ORGAN OR TISSUE r • ATION BEEN CONSIDERED?
<br />❑ YES i°I e
<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 />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />73a. REGI
<br />RAR'$ SIGNATURE
<br />j ever ,r i'
<br />28b. DATE FILED BY REGISTRAR(Mo.,Day, Yr.)
<br />December 16, 2019
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