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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE $TATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE IA 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 />3/1/2017
<br />LINCOLN, NEBRASKA
<br />202006365
<br />STANLEY S. DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (Firyt, .' . Middle, Last, Suffix)
<br />Marilyn Elaine Houghton
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 17, 2017
<br />�4 GITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sterling, Colorado >'-
<br />7. SOCIAL SECURITY NUMBER.,-, r,
<br />.521-64-7877 •
<br />• ".
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />-rne eon
<br />FACILITY -NAME (If nottnatittrdon give street and number -:
<br />CHI health St. Francis
<br />W • 8c. CITY OR TOWN OF DEATH(Include Zip Code) --- -
<br />Grand Island 68803
<br />8a. RESIDENCE.STATE
<br />z Nebraska
<br />9d. STREET AND NUMBER'
<br />u-
<br />3048 St. Paul Rd
<br />10a. MARITAL STATUS AT TIME OF DEATH®iMIrrttdr 0 Never Married
<br />❑ .Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FA't R'S -NAME (First, Middle, Lait; `' Suffix)
<br />• Willis Crowell
<br />8a. PLACE OF DEATH
<br />M61'.Lr
<br />HOSPITAL '® Inpapsntu. . OTHER 0 Nt((}lr1)' Hpi TC ,,;❑,I('oepice Facility
<br />] EWSTR
<br />9b. -COUNTY- --
<br />Hall
<br />70
<br />5b UNDER;1 YEAR
<br />5c. UNDER 1 DAY
<br />Roar
<br />DAYS
<br />HOURS
<br />MINS. .
<br />B.. DAT OF BIRTH (Mo., Day, Yr)
<br />-"October 31, 1946
<br />0
<br />Yt DOA - -
<br />F - ❑ Other(Specify) --
<br />UC' eh.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS?
<br />❑ YES E NO
<br />10b. NAME QF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Cary D : Houghton
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Eleanor Anderson
<br />E•
<br />ir 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />g (Yes; No, or Unk.) NO
<br />14a. INFORMANT -NAME
<br />Gary D Houghton
<br />1s. METHOD OF DISPOSITION -
<br />° ❑ Burial ❑ Donation
<br />E Cremation 0 Entombment
<br />Removal 0 Other (Specify)
<br />'1841- EMBALMER -SIGNATURE
<br />Not Embalmed
<br />tab, LICENSE NO.
<br />1$d.'E'METERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY I TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse'
<br />18c. DATE (Mo.; i ir.i.
<br />Febnjari 17,' 101
<br />::CAI
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MiGLING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chanel. 36O5 S. Locust St., Grand Island. Nebraska
<br />• OL
<br />r
<br />tf CAUSE OF DEATH (See instructions and examples •
<br />TS. PART'. Enter the chain -of -events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,- .. - . T-APPROXtMATE INTERVAL.
<br />respiratory *meek or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEgU1TE,CAUSE:- -
<br />IMMEDIATE CAUSE'(Final al Muscular Dystropflyt
<br />disease or condition-resuaktg
<br />in sierra.).
<br />Sequentially list conditions, N
<br />any, feeding tether Cause listed
<br />on line a
<br />Exner the UNDERLYING CAUSE
<br />tdiseaee a injury Ha4t initiated
<br />the events riteuainpin death)
<br />LAST
<br />DUE TO, ORAS ACONSEIQUENCE OF:
<br />..xsvre t'rn.,;:
<br />DUE fn, -OI KS A -CONSEQUENCE OF:
<br />DUET)); ORAS A CONSEQUENCE OF:
<br />d) Cr
<br />onset to death'
<br />Years' '
<br />' 0
<br />4St1441 ..
<br />, Jib,,;t,-;
<br />18. PART II. OTHER SIGNIFICANT CONDITIO)iS Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Metastatic Uterine Cancer,
<br />20. IF FEMALE: -
<br />E Not pregnant within past year •,1
<br />,.
<br />W .a
<br />•..AAI. CVjC'
<br />t 0 Pregnant at time of death-_ . -
<br />• ❑ Not pregnant, Out pregnant within 42 days of death
<br />❑ Not pregnera, but pregnant 42 days tfl•t year Sefote death
<br />❑ Unknown if prepnant Miele the past year l L.
<br />E 22a. DATE OF INJURY (Mo.,' Day, Yr.)- " •
<br />u
<br />22d. INJURY AT WORK? .
<br />AYES ANG
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homlelde
<br />0 Accident ❑ Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />;27b. -TIME -OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other.(Specify)
<br />19. WAS MEDIGAL1.yEITAMINER
<br />OR QgRON F- NTACTED?
<br />❑ YES 5a iO1
<br />21c. WAS AN Al TOPS'f,P ORMED?
<br />❑YES ®NCI.h "
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO -
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY_ OCCURRED
<br />t- 1 Cali
<br />22f. LOCATION OF INJURY- STREET & NUMBER,- '-APT.NO
<br />CITY/TOWN
<br />STATE 'ZIPCODE "
<br />23a. DATE OF DEATH (Mo., Day, Yr.) _._. _.
<br />F5February17 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c, TIME OF DEATH
<br />iz February 17 2017 '`0et0AM
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />B g and due to the cause(s) staled. (Signature and Title)
<br />W Travis S, Hageman, MD •-
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES &i NO b PROBABLY 0 UNKNOWN
<br />-24a..DATESIGNED (Mo., Day, Yr.) .: - . 24b. TIME OF DEATH
<br />1-m- t; Ov lir,*.',..•'-AAI -
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr24d. TIME PRONOUNCED DEAD
<br />-410,n:bac/at:. ---•
<br />,_ Lam' Ita<! 40'7
<br />24w.4ftilie_basis of examination and/or ineestigiadothinnty opinion death o4Gutted at
<br />plebes"), date and place and due to the eitiEefirRiebd. (sigrtatuniand Tafe)-
<br />"IH
<br />26a. HAS:ORGAN OR TISSUE DORADO/1 BEEN CONSIDERED?
<br />❑ YES,' H` ENO ^fpt-
<br />27. NAME, TITLE AND ADORES OF CERTIFIER (Type or Print
<br />Travis S. Hageman MD,729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />JO -
<br />26b. WAS CONSENT GRANTED? I'
<br />Not Applicable Ifi8a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 21, 2017
<br />1
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