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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 TRITE 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 OFISSUANCE
<br />12/3/2018
<br />LINCOLN, NEBRASKA
<br />202101210 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTHAND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Udell Gene Jess
<br />4. CITY ANOMIE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Farwell, Nebraska
<br />A 7. SOCIAL SECURITY NUMBER
<br />508-66-4864
<br />5a. AGE • Last Birthday.
<br />(Yrs.)
<br />Bb. FACILITY•NAME (If not Institution, give street and number)
<br />S+ CHI Health St. Francis
<br />to
<br />5 8c. CITY OR TOWN OF DEATH (Include Zip Cade)
<br />Grand, Island 68803
<br />9a RESIDENCE•STATE
<br />Nebraska
<br />c , 9d. STREET AND NUMBER
<br />1703 Doreen Street
<br />10a. MARITAL STATUS AT TiME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />e 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Otto Jess
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Na
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal : 0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />82
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Me., Day, Yr.)
<br />November 16, 2018
<br />6. DATE OF BIRTH (Mo. Dayl
<br />August 19, 1936
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />„❑ Hospice Facility
<br />9g. INSIDE cITY' LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Joyce Pedersen
<br />1 12. MOTHER'S -NAME (First, Middle,
<br />Della Carstens
<br />Maiden Surname)
<br />14a. INFORMANT -NAME
<br />Joyce Jess
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />November 19, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska
<br />m
<br />5 ..
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />176. Zip Code
<br />68801
<br />CAUSE OF DEATH(See instructions=#nd examples)
<br />S. PART!. Enter **Chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrM t, or Wintdeular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cense one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Anterior ST Sement Myocardial Infarction
<br />IG IMMEDIATE CAUSE (Final
<br />e disease or condition resulting
<br />10
<br />Sequentially
<br />any, kladin9
<br />on line a.
<br />list conditions,. If
<br />to the Ceustt1i14ed
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury** Initiated':
<br />the events resulting in omen
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />13)Coronary Artery Disease
<br />APPROXIMATEINTERVAL
<br />onset to death
<br />6 Hours
<br />onset to death
<br />Months
<br />DIE TO, OR A? A CO! CEQUENCE OF:
<br />C)
<br />onset to 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 1.
<br />�. IF FEMALE:
<br />r
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Nat pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown Remanent within Inc past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF. TRANSPORTATION
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER � CONTACTED?t
<br />fa ❑ YES NO
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />OYES ❑ NQ
<br />22f. LOCATION OF INJURY • STREET 8, NUMBER, APT.NO.
<br />C F u
<br />3 g O
<br />o
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />November 16, 2018
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />P)OVrnl±er 10 2018 07: 1 v ?TA
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due t0 the cause(s) stated. (Signature and Title)
<br />Jeffrey S. King, MD
<br />25. DID TOBACCO USE >rONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />24b. TIME OF DEATH
<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 pian and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jeffrey S. King, MD, 715 N Kansas Ave, Suite #200, Hastings, Nebraska, 68901;
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR {MO., Day, Yr.)
<br />November 30, 2018
<br />
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