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SIA klae py € Meat 1 1l 1,413itiaatta$t(B'F1 'iii3fi ;dE1 a3 A7I(iN�;zlt�avttxt�..a��t90g ��A'�3#?u�Rt$tii�I��(I3$•F`/�\C�Wdu traimmab cti r; 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 OF ISSUANCE 9/10/2020 LINCOLN, NEBRASKA Amended 202007167 Jelt•ICI°) 04-VW/kit re SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTSNAME (First, Middle, Last, Suffix) June Joleen McDowell 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 510-30-2585 5a. AGE • Last Birthday (Yrs.) 8b. FACILITY -NAME « not Institution, give street and number) 1118 N. North Road 8c. CITY OR TOWN Grand Island 86 Sb. UNDER 1 YEAR 2. SEX Female 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA HOURS MINS. 20 03347 3. DATE OF DEATH (Mo., Day, Yr.) March 8, 2020 6. DATE OF BIRTH (Mo., Day, Yr.) June 23, 1933 OTHER 0 Nursing Home/LTC Decedent's Home 0 Other (Specify) Off DEATH (Include Zip Code) Bd. COUNTY OF DEATH 68803 Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 0 Hospice Facility 9d. STREET AND NUMBER 1118 N. North Road Be. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS. ❑ YES®NO', 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Everett McDowell 11. FATHER'S -NAME (First, Middle, Lest, Suffix) Garth Holmes 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Erma Burgess 13. EVER IN U,S.ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Everett McDowell 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION Burial ❑Donation 0 Cremation <❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) March 20, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION Fairview Cemetery 17a. FUNERAL HOME. NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CITY / TOWN Smith Center CAUSE OF DEATH (See instructions and examples) 1S. PART I. Enter the chain of events- diseases, in)urles, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on ■ line. Add additional lines If necessary. IMMEDIATE CAUSE: a) Failure To Thrive IMMEDIATE CAUSE (Final disease or condition resulting: In death) Sequentially list conditions, If any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (diesass or In)uty:that initiated the events resulting In death) LAST DUE TO, OR AS A CONSEQUENCE OF: b)Cerebrovascular Dementia DUE TO, OR AS A CONSEQUENCE OF: c) Cerebrovascular Disease DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART 11.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Hypertension, Chronic Kidney Disease 20. IF FEMALE: ❑ Not pregnont within pot year ❑ Pregnant et time of death 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 224, DATE OF INJURY (Mo. Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 21e. MANNER OF DEATH ENatural 0 Homicide 0 Accident 0 Pending Investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger ❑ Pedestrian D Other (Specify) STATE Kansas • 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 6 MonthS onset to death 10 Years onset to death 10 Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY';, STREET & NUMBER, APT.NO. CITY/TOWN c at a 23a. DATE OF DEATH (Mo., Day, Yr.) March 8. 2020 23b. DATE SIGNED (Mo., Day, Yr.) March 12. 2020 23c. TIME OF DEATH 06:10 PM 23d. To the beet of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Sara Gravbill, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE <: 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investiga ion, in my opinion death occurred et the time, date and place and due to the cause),) stated. (Signature and Title) ,. 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES RI NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sara Graybill, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE Dt- Iasi Ba y 2eb. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 17, 2020 Amended 9/10/2020 Item 1 Corrected First Name And Middle Name From Joleen June To June Joleen CD c) CAD