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<br />STATE OF NEBRASKA
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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
<br />DATE OF ISSUANCE
<br />1/18/2017
<br />LINCOLN, NEBRASKA
<br />202008268
<br />Cop
<br />STANLEY S. COOPER
<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 (First, Middle, Last, Suffix)
<br />Marilyn Dale Arrants
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-56-091.3
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />$p, FACILITY -NAME (If trAltistitution, give street and number)
<br />1304 Mansfield Road
<br />re 8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />c Grand Island 68803
<br />9a. REStDENCE.STATE
<br />w Nebraska
<br />2 9d. STREET AND NUMBER'
<br />LL
<br />,. 1304 Mansfield Road
<br />a
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ WIdowed ❑ Divorced 0 Unknown
<br />9b. COUNTY
<br />Hall
<br />69
<br />SO. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 6, 2017
<br />6. DATE OF BIRTH IMO:. Day, Yr.)
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (SpecIfy)
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9C, CITY OR TOWN
<br />Grand, Island
<br />90. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. tNSIOE CITY LIMITS
<br />® YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Donald LeRoy Arrants
<br />11. FATHER'S -NAME (First; Middle,
<br />I Charles Scott Lucas
<br />E13. EVER IN U.S. ARMED FORCES? Give dates of service if Yea.
<br />(Yet, No, or Unk.) No
<br />2 15. METHOD OF DISPOSITION
<br />IO- ❑ Burial 0 Donation
<br />Cremation 0 Entombment
<br />0 Removal <❑ Other (Specify)
<br />Last, Suffix)
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Patricia June Rhoades
<br />14a. INFORMANT -NAME
<br />Donald LeRoy Arrants
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />169. LICENSE NO.
<br />1092
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.);
<br />January 12, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chanel. 3005 S. Locust St.. Grand Island. Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH pee instructions and examples)
<br />PART/. Enter the chain of events. -diseases, injuries, or complications -that directly caused the death, DO NOT enterlentnnal events such as cardiac arrest,
<br />re4yfiratety street, or MaiarFCtllar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause On a Ilne. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Abdominal Cavity Abscess
<br />disease or condition resultlrg
<br />In death)
<br />Baoeeftially fiat COMHtfotsa, H s
<br />any, leading lathe cause listed
<br />on fine a.
<br />Enter the UNDERLYING CAUSE
<br />(disease a/njury that Initiated::
<br />On event* restating hi death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Biliary Stricture
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Locally Advanced Adenocarcinoma of the Gallbladder
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />17b. Cot10
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />7 Weeks
<br />onset to death)
<br />7 Weeks
<br />onset to death
<br />8 Weeks
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Diabetes, Parkinson's Disease, Hypertension, H/O Breast Cancer, Obesity, Venous Stasis Changes, DVT Right Leg,
<br />ct Obstructive Sleep Apnea;,
<br />0. IF FEMALE:
<br />Not pregnant -within past year
<br />:Wi 0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />foli:❑ N4t pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown gpregnintwithin the past year
<br />E22a. DATE OF INJURY (Mo., Day, Yr.)
<br />0
<br />u
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Othai (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />di
<br />so
<br />0
<br />2d. INJURY AT WORKS
<br />❑YES ONO
<br />22b. TIME OF INJURY
<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 />I22f. LOCATION OF INJURY • STREET S NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 6, 2017
<br />23D. DATE SIGNED (Mo., Day, Yr.)
<br />January 11, 2017
<br />CITY/TOWN STATE
<br />23c. TIME OF DEATH
<br />06:15 PM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />TIP COD1F•
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUN© 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 and TRIM
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED?
<br />0 YES Ea NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES Et NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A, Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />$a. REGISTRAR'S SIGNATURE 3- C
<br />26b. WAS CONSENT GRANTED?'
<br />Not Applicable If 26a is NO O. YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR(MO.,Aay,Yr.)
<br />January 12, 2017
<br />
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