|
nIt 11(a111.f1081I1a,,Ty1
<br />g1��a1�!�i��q 46M�1MI�.x +."ms4sY6tlINAiAI11..
<br />�t'111n,ss18�
<br />3 # �?�01rtt9yftttasl:".. irlrgrnttw t .r...;4z.. -
<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 OFISSUAAfCE
<br />2/10/2021
<br />LINCOLN, NEBRASKA
<br />202101454
<br />c-,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OE HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 01688
<br />DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Mary Ann Heftier
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (No.s Day, Yr.)
<br />February 2, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />Ba. AGE - Last Birthday
<br />(Yrs.)
<br />72
<br />8b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF BIR'C'H (Mo., Day, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />506-60-8170
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />October 411948
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />246 Carey Street
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br /># Yes # IJO
<br />10e, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Larry Milton Hettler
<br />11, FATHER'S.NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Floyd Lamphear Gladys Vogt
<br />Middle, Maiden Surname)
<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 />Larry Milton Hettler
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />1a Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />February 5, 2021
<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 MA LING 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 />CAUSE OF DEATH (See instructions and examples)
<br />16. PART I. Enter the chain of events- disuses, 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 linea if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final al Failure To Thrive
<br />disease et t:ondition moulting
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />online I.
<br />Enter the UNDERLYINGCAUSE
<br />(Maestri or injury that' initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />10 pays
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Spontaneous Intraparenchymal Cerebral Hemorrhage
<br />onset to death
<br />1 Hour
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset tO death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTII, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE::.
<br />Not pregnant wit In past year ..
<br />0 Pregnant at 6m°61.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 Pregnent within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />❑ Accident ❑'Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY -FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22s; DATE OF INJURY (Mo., 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 & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 2, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />o
<br />February 2. 2021 09:57 AM
<br />. To the beet of my knowledge, death occurred at the time, date and place
<br />and due tothe cause(s) stated. (Signature and Title)
<br />Manoi Suryanarayanan, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 1 NO ",❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e, On the basis of examination and/or investigation, in my opinion death eecuresd at
<br />the time, dart and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO " 0 YES
<br />27', NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Marroj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />`364-Ati Bali rc,�r�m�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 9, 2021
<br />
|