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ISS't i auu tAWit"' °gllcg2PdW3sau nawgt Nggn> few ser ceq WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR, VITAL RECORDS DATE 66OFISSUANCE 5/1g/2013 NEBRASKA W cc 1 a 1 n 10- 202004306 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Joyce Elora Gydesen 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) February 18, 2018 4.CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH York, Nebraska 7. SOCIAL. SECURITY NUMBER 506-56-2908 5a. AGE - Last Birthday (Yrs.) 73 So. FACILITY -NAME (If not institution, give street and number) CHI <Health St. Francis 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA HOURS MINS. 6. DATE OF BIRTH (Mo., Day, -Yr.) June 18, 1944 OTHER ® Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) 0 Hospice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 800 Stoecier Dr. 9b. COUNTY Hall 8d. COUNTY OF DEATH Hall 9C. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY': LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Duane Gydesen 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12 MOTHER'S -NAME (First, Middle, Maiden Surname) Joy Barr Elora Gelvin 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, Noor Unit.) No 15. METHOD OF DISPOSITION El Burial 0 Donation ❑ Cremation 0 Entombment ❑Removal '0 Other (Specify) 14a. INFORMANT -NAME Duane Gydesen 14b. RELATIONSHIP TO DECEDENT Husband 16a. EMBALMER -SIGNATURE Stacie L. Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.);. February 22, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 11. PART I. Enter the Chain of events- diseases, injuries, or complications -that directly untied the death. DO NOT enter terminal events such as cardiac arrest, respiratory street, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only, one taus* on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) lschemic Bowel disease or condition resulting sequndiauy list cor)!ditron$, if anv, leading to the eau** iistad on line Y Enter the UNDERLYING CAUSE (alms* or Injury that Initiated the svente resuttl 1p: in Mph LAST APPROXIMATE INTERVAL onset to death 2 Weeks DUE TO, OR AS A CONSEQUENCE OF: b)Renal Failure onset 10 death 2 Weeks onset to death 2 Weeks DUE TO, OR AS A CONSEQUENCE OF: c) Sepsis To lschemic Bowel DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO" 20. IF FEMALE: Not pregnait within past year ❑ Pregnant at time a death o NotMeenent. Dis pregnant within 42 days of death QNa prepnsM put pregnant 43 days to 1 year before death ❑ Usltrttiwn S ptipnant wlthin the past year 21a. MANNER OF DEATH El Natural ❑ homicide 0 Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY CI Driver/Operator 0 Passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22cf. INJURY AT WORK? ❑YES El NO 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) February 18, 2018 uary ly, 3d. To tie best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Kenneth Vette', MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY 0 UNKNOWN Di iIqni<zJZ W = 34e. On the basis of examination and/or Investigation, in my opinion death occurred at gp the time, date and place and due to the cause(s) stated. (Signature and Title) 8 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ElNO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Kenneth Vette', MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE / A - 28b. DATE FILED BY REGISTRAR February 22, 2018 (Mori Day, Yr.)