|
ItitiON1920iacioniii;;LiginVimitiu;mitiiimmilattejlomeoi Rpm
<br />IStix, Tk49
<br />tyyrALvt y trt�pgtas* aO M!Atry � 1tlt
<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 />2/21/2020
<br />LINCOLN, NEBRASKA
<br />1
<br />5
<br />E
<br />fi
<br />8
<br />202001040
<br />39-.44.11 0844-4,01.6t
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alma Mae Dee
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Greeley County, Nebraska
<br />7. SOCIAL SECUPJT`.' NUMBER
<br />507-34-5608
<br />6b. FACUTY-NAME Sint Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />tic. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68863
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - LAM Birthday
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />89
<br />. Ba. b' .!SCE eF CE Tr'
<br />HOSPITAL 0 Inpatient
<br />n ER/Outpatient
<br />❑ DOA
<br />DAYS
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 02049
<br />3. DATE OF DEATH (Mo., Day, Yf)
<br />February 9, 20201
<br />8. DATE OF BIRTH (Ma, Day, W.)
<br />January 20, 1931.
<br />OTHER ® Nursing Home/LTC
<br />n Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />2920 W 13th St
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY UMrrs
<br />la 'YES 0 NO
<br />tab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Raymond Edward Dee
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Elmer Wilson Gydesen
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Martha Bennett
<br />2
<br />i
<br />O
<br />I
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes..
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Raymond Edward Dee
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />Q CrematiOn 0 Entombment
<br />Removal ❑ Otter (specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />February 22. 2020
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Mount Hope Cemetery Scotia
<br />STATE
<br />Nebraska
<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 />11. PART I. Enter the
<br />raplratory amscth, aot r vsdnwMcular rodhrultiaatlposn wIn0juMriaut ,sohrocvoimnptfacadeotimologyaMt
<br />.DDdireNcT ABaussd
<br />BREVtiIA. EdaEnr
<br />.ti.teDrO oNOT
<br />oansntear utearoinaal ewa. dAsdsducadhdtabcard
<br />ml lianoarMest,
<br />nscsswry.
<br />1 19DIATECAUL (Fbul
<br />disease or **diem resetting
<br />kr Mph)
<br />Sequentially 1st conditions, if
<br />any, leading to the awe listed
<br />online
<br />Entor tit UNDBRLYINO CAUSE
<br />(diaaatte er Inlery that initiated
<br />the events mulling In death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) GmaIlBo4eI Cbsiruction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Bowel Leak
<br />17b. code
<br />68801:
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />vVeeks
<br />onset to death
<br />Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Intra Abdominal Abscess
<br />onset to death
<br />Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Malnutrition
<br />18, PART II. OTHER SIGNIFICANT. CONDrONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />OId Not Improve Post Operatively And Transitioned To Hospice And Died
<br />onset to death
<br />Prior
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />. IF FEMALE:
<br />© Not pregnant within peltyear
<br />❑ Preen*** bete Wilke*!
<br />0'f4gtpregneat, but pregnant within 42 days *death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />o Accident 0 Pending Inveartiafeon
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />;.Q Driver/Operator
<br />0 Passenger
<br />© Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO >_
<br />22a.:DATE OF INJURY IMO., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />CITES ❑ NO
<br />i t^ „rl wi c.-1. tit. it ray. eTeFET *,NUMBER. APT NO.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 9, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 14.2020 12:55 PM
<br />3d
<br />btu* best ofs y knowledge, death occurred at the One, date and place
<br />and due to threarw(s) stated. (Signature and TMH)
<br />Michael A. Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />I[
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE ANI) ADDRESS OF CERTIFIER (Type or Print
<br />Michael A Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD.
<br />24e. on the basis of examination and/or investigation, M my opinion death occurred at
<br />are erns, date and piece and due to the cause(a) stead. (Signature and Ties)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />28a. REGISTRAR'S SIGNATURE
<br />61-44.17
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 VES
<br />❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 19, 2020
<br />
|