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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
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<br />DATE OF ISSUANCE
<br />6/16/2020
<br />LINCOLN, NEBRASKA
<br />202004594
<br />7
<br />ri,3,1�? ��='df ..r "f!. ',Ci f yf ,^
<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 />20 07585
<br />DECEOENTS.NAME (First, Middle, Last, Suffix)
<br />Melinda Lee Bellew
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Bio., Day, Yr.)
<br />June 8, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Eureka, Kansas
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH lMo., Day, Yr.)
<br />March 8, 1940:
<br />7. SOCIAL SECURITY NUMBER
<br />515-38-8799
<br />a 8b. FACILITY-NAME(If not not Institution, give street and number)
<br />d
<br />331 E. South St.
<br />O
<br />rA
<br />2
<br />Ba. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68801 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />❑ Hospice FaCi£ity
<br />9d. STREET AND NUMBER
<br />331 E. South St
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />94. INSIDE CITYLtMITS;•
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated 1 Widowed 0 Divorced 0 Unknown
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Glen Bellew
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Everett Benton >'
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Thannie Evelyn Dye
<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 />Robyn Bellew
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />®`Burial ❑ Donation
<br />❑',Crentation; 0 Entombment
<br />❑ Removal ' ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />June 11,'2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<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 />17b. Zip Code
<br />68801
<br />deceased are filed with t
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal 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 />IMMEDIATECAUSE (Final a) Metastatic Colon Cancer
<br />fa411Sse of condition resulting
<br />m death( DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Ilst conditions, If b)
<br />any, leading to the :cause listed
<br />on tinea.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />6 months
<br />onset to death
<br />onset 03 death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to 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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE
<br />❑ Not pregneot within pea Year
<br />❑ Pregnant ages 01 death
<br />0 Not pregnant, but pregnant within 42 days of 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 />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES 0 NO
<br />22a, DATE OF INJURY (Ma: Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />YES , ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.'LOCATION'OF INJURY! STREET 8 NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />9 ▪ e
<br />1• :1
<br />z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 8, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 9, 2020 01:26 PM
<br />Y 0 To the bast Only knowledge, death occurred at the time, data and place
<br />C : and due to the cause(s) stated. (Signature and Title)i°-
<br />Shu -Ming Wang, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />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 onetime) a:
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES] NO] PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES
<br />E:1 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shu -Ming Wang, MD, 908 North Howard Avenue Ste 109, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />6k.-4,2-17
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 11, 2020
<br />
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