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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 DEPOSITORY FOR VITAL RECORDS de
<br />DATE OF ISSUANCE RUSSELL EOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARCMENT OF HEALTI!
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIPICATE OF DEATH
<br />8/2/2019
<br />LINCOLN, NEBRASKA
<br />202002016
<br />1. DECEDENTS -NAME (First, Middle, Last. Suffix)
<br />Dou t las Alvin Denman
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand.(sland, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />807-x, 0193.
<br />$b. FACILITY•NAME (If not Institution, give street and number)
<br />5a, AGE - Last Birthday
<br />(Yrs,)
<br />71
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />aluo ttpetiva
<br />Sb. UNDER <1 YEAR
<br />MOS
<br />2. SEX
<br />Male
<br />CHI Health' St. Francis
<br />Sc. CITY OR TOWN OP DEATH (Inelu
<br />Grand !eland , 88803
<br />3a< RESIDENCE,STAT8
<br />N braska
<br />DQA
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />July 1.201
<br />6. DATE OF BIRTH (Mo., Day, Ye.)
<br />.duly 6, 1947
<br />QTHSR Q Nursing HomelLTO
<br />Q Decedent** Horne
<br />Q Other (Specify
<br />6d. COUNTY OF DEAN
<br />flail
<br />3d. STREET AND NUMBER
<br />3700 S. Alda
<br />lob. MARITAL STATUS AT TIME OF DEATH E0 Married 0 Never Married
<br />Manfred, but separated;: 0 Widowed 0 Divorced 0 Unknown
<br />Eep Cede)
<br />0 Hospice Facility
<br />Sb. COUNTY
<br />Hall
<br />3e. CITY 0
<br />Alda'
<br />!e. APT. NO,
<br />11. FATHER'S -NAME (Ffr*t, Middle, Last, Suffix)
<br />Alvin Denman
<br />10*, NAME OF SPOUSE (First, ;Middle, Last,
<br />Marilyn Ransack
<br />6f. ZIP CODE !g. INSIDE CITY LIMITS
<br />68810 0 YES NO
<br />Suffix) 1f wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle,
<br />Josephine Klinkicek
<br />Maiden Surname)
<br />13, EVER IN U.S, ARMED FORCES? Give dates of service If Yes. 114a. INFORMANT -NAME
<br />(Yes No, or link.) Yee 05/13/
<br />968-07/13/1969 Marilyn Denman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />6. MtTHOA OF DISPOSITION
<br />® Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />E] Removal 0 Other (Specify)
<br />18e. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />1613. LICENSE NO.
<br />1454
<br />18c. DATE (Me., Day, Y►,)'
<br />July 10, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cameron Cemetery
<br />7a. FUNERAL HOME NAME ANO MA LING ADDRESS (Street, City or Town, 81ata)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY I TOWN
<br />Wood River
<br />STATE
<br />Nebras
<br />17b. Zip -ode
<br />68801
<br />15
<br />A Y E e F its iristr)cttonion. exam) as)
<br />PAY;TY. Emarexr:mum of events- -disease*, Injuries, or compllsations-lhet directly caused the death 00 NOT enter terming events such as cardiac arrest,
<br />mealrat*ry eK_ or wMrlCpl r fibrillation without showing the etiology. 00 NOT ABBREVIATE. Ent* F only one coupe *tr a Ilse. Add additional lines R necs$MW.
<br />IMMEDIATE CAUSE:
<br />a) Hemorrhagic Shock
<br />IMMEDIATE CAUSE (Final
<br />disaasa Or condition resulting
<br />ie duan)
<br />Seton lolly Est 1004131ena, it
<br />any. lae01n6ta the *Sties Ilste4
<br />on lima.
<br />Enter the UNDERLYING CAUUI6
<br />Misses* er rnjary that IMtlatsa
<br />Lae pines r1atrama In death)
<br />LAST
<br />DUE 70, OR AS A CONSEQUENCE OF:
<br />b) Cardlac Arrest
<br />APPROXIMATE INTERVAL :
<br />onset to depth
<br />Minutes
<br />onset to death
<br />Minute*
<br />DUE TO, OR AS A CONSEQUENCE OP;
<br />c) Unknown
<br />onset to death
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />d)
<br />onset (o 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 />28. IF FSMALJi:
<br />0 Not pregnant *Man Met year
<br />Pregnant st E1ne dr death
<br />© Nqt prsipNnd. pip preananl whhin AS deye *1 death
<br />Q Net pre9100t, evt plslnant a days to 1 year be►aro death
<br />0 Urdnewn B pregnant wenn Eta MN year
<br />22a. DATE OP INJURY (Mo., Day, Yr.)
<br />22d. INJURYAT': WORKT
<br />0 YES
<br />NO
<br />21a. MANNER OF DEATH
<br />® Nature! 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide Scold not be dsexrmk+pd
<br />22b. TIME OF INJURY
<br />21b. IP TRANSPORTATION INJURY
<br />0 Drivemsperater
<br />0 Passenger
<br />Q Padeatrian
<br />Ot ar(BPesxy)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />[1 YES al NO
<br />21d, WERE AUTOPSY PINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />[� YES Q NO
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (SpecIfy)
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO.
<br />298. DATE
<br />OF DEATH (Mo„ Day, Yr.)
<br />CITY/TOWN
<br />Ib. DATE MONO (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />1 240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />STATE
<br />24a. DATE: SIGNED (Mo., Day, Yr.)
<br />Atpust2, 2019
<br />24b. TIME OF DEATH
<br />07:30 PM
<br />?JP CODE
<br />Sd. To the best o1 my knowledge, Wath occurred at the tons, date and plata
<br />end due to the cause(s) stated. (Signature and TED)
<br />E
<br />25. DID TOBACCOuse CONTRIBUTE TO THE DEATH?
<br />E] YES f NO 0 PROBABLY ® UNKNOWN
<br />Jyly 1, 2019
<br />24e. On the bests Of examination andPor irlWetlgaUon, kI my OpinNn ilaa8l eaeurred
<br />the time, data and place and dos to the *ause(s) stated. laienature and TWO
<br />3 Kate Collins, Hall Deputy County Attorney
<br />24d. TiME PRONOUNCED DUO
<br />07;30 PM
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />O YE8 E1 N0
<br />21b. WAS CONSENT GRANTED?
<br />Not Applicable if 26e le NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS -OF CERTIFIER (Type or Print
<br />Kate Collin#, Hall Deputy County Atterne , 231 S. Locust, Grand Island, Nebraska, 68801
<br />28.. REGISTRAR'S SIGNATURE?
<br />28b. DATE FILED BY REGISTRAR 040, Day, Yr.) 1
<br />August 2, 2019
<br />
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