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<br />� STATE OF NEBRASKA J )
<br />it yNt ,,l7 4r'Wr I /... •y )ir �Cii00"""7/ill n a1 Il�d7 Kii'�(t�tlur'Ir��
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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 TRITE 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 />3/24/2020
<br />LINCOLN, NEBRASKA
<br />2020019
<br />61. fhAkibiwket
<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 />Doris ::: Romona McLellan
<br />4. City.' ND STATE OR'1'ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />South Shore, South Dakota
<br />7. SOCIAr_SEC IRITYNUMBER
<br />IL;
<br />504-18-0080
<br />rt• 8b. FACILITY -NAME (If not Institution, give street and number)
<br />as
<br />Tifffr.Y Square Care Center
<br />• 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Istand 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER.
<br />4236 W. 13th Street
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last;Birtbday
<br />(Yrs.)
<br />92
<br />5b, UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ERFOu patient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH I I Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER S.NAME (F(ritt, Middle,
<br />WaRer Mever
<br />Last, Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />v
<br />E
<br />u
<br />(Yes, No, or Unk.).No
<br />15. METHOD OF DISPOSITION
<br />gl Burial ❑ Donation
<br />13 Cremation ❑ Entotrnxnent
<br />Remover #. ❑Other (Specify)
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />16 03690
<br />3. DATE OF DEATH (MO., Day Yr.)
<br />June 24, 2016 .' .
<br />6. DATE OF BIRTW(Mo., Day, Ytf)
<br />October 9, 1923
<br />OTHER gl Nursing Home/LTC
<br />0 Decedent's Home
<br />Ott; ISpecity) •
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />le. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />99. INSIDE CITY LIMITS
<br />12 YES ❑ NO
<br />10b. NAME OF SPOUSE (First," Middle, Last, Suffix) If wife, give maiden name
<br />William McLellan III
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />C Ruby Roberts
<br />14A. INFORMANT -NAME
<br />William McLellan III
<br />16a. EMBALMER-SIGNATURE
<br />M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />17a.. FUNERAL:. HOME; NAME AND MAILING ADDRESS (Street, City or Town,; State)
<br />All Faiths; Funeral Home, 2929 S. Locust Street, Grand !siertd�Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART I. Enter the chain of events- diseases, In uries, or complications -that directly caused the death. DO NOT enter terminal events such a cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showin0 the etiaoov. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ones it i, cessarv.
<br />IMMEDIATE CAUSE:
<br />a)Chronic Renal Failure
<br />tfi MIM TATE CAUSE (FBtal
<br />attl111p
<br />In dsadll
<br />dfsaaaaoreondgian re
<br />II;
<br />WSequentially list conditions, if b) •
<br />any, leading to the cause listed
<br />oniMea
<br />CUE TO, OR ASA CONSEQUENCE CF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />�m : Ester the UNDE*LYINGCAU5E C)
<br />'6 (dinar* or in)WY that initiated
<br />lis "wets resulting in deedm) DUE TO, OR AS A CONSEQUENCE OF:
<br />LIST d)
<br />A 18, PARTE OTE(ER SIGNIFICANT CONDITONS•Conditona contributing to the death but notrsu(ting'in the underlying cause given In PART I.
<br />Diabetes Mellitus Type 2, Adenocarcinoma Of Lung, Hypertension, Alcoholic Cirrhosis
<br />• •
<br />• ,. IF FEMALE:,.
<br />I❑Not-�
<br />pn9tyldrtwistrnFaetir"ar
<br />u,# Pregnsa Lira of death
<br />.: ❑:. Not pregnant, bid:pregrant within 42 days of deeM
<br />M0 Not pregnant, but pregnant 43 days to 1 yew before death
<br />C , ❑,; Unknown If pxegpm.nt within the put year
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo
<br />July 2.201
<br />Dey, Yr.)
<br />6
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 Years
<br />onset to death
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTED?
<br />❑ YES ®NO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide .
<br />❑ Accident 0 Pending Investigation
<br />❑ suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Speedy)
<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 />E 22a::;;DATEO!H.I.JURY{INtr.,;Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />home, farm, street, factory, office building, construction site, ego, {Specify)
<br />E 22d. INJURY AT WORK? j220. DESCRIBE HO'N INJURY OCCUR DED
<br />•
<br />❑ YES ❑ NO
<br />22f. LOCATfO#IOF INJUR`1 STREET & NUMBER, APT.NO. CITY/TOWN
<br />a.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 24, 2016
<br />23b. DATE S!fMED (Mn., Day, Yr:) 23c. TIftl OF DEATH
<br />June 28, 2016 08:07 AM
<br />234. TOR* Wei of my.knowledge, death occurred at the time, date and place
<br />Auks Wa tnthu:wuse(s) stated. (Signature and Title)
<br />Adam Brosz, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ',❑ PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCE DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, M my opinion death ooCtirred et
<br />the t1ee, date and place and due to the cause(s) stated. (Signature And his)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES RI NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES
<br />0 N
<br />27.;NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adam Brosz, MD 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a.REGISTRARSSIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 30, 2016
<br />U"1
<br />
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