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`�`�),alViit i (IiI, rrtam ta3�.dI.A1'6'Idt.SS,a�..ista6NP,mne14rSiESd/GeJadNi:3 1111,1/141lk6iaeOgre °Btnnt9uMact rtatd144gtlll`u`ISaa�? sttitraiillltal°'„. ?f 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 1 /27/2021 LINCOLN, NEBRASKA tb E 0 202101913 ata a_, = .ya. fil.trt,m SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. pECEDENT'$-NAME (first, Middle, Last, Suffix) Joy Martin Beazley 4. CITY AND $TATE OR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH Washta, Iowa 5a. AGE - Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 21 00651 3. DATE OF DEATH (Mb., Day, Yr.) January 14, 2021 6. DATE OF BIRTH (Mo., Day, Yr) August 27,1933. 7. SOCIAL SECURITY NUMBER 482-38-2304 8b. FACILITY=NAME of not Institution, give street and number) #16 St. James Place 8c, CITY OR TOWN OF DEATH (Include Zip Code) 'Grand Island 88803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER 0 Nursing Home/LTC E Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall ❑ Hospice Facility 9d. STREET AND NUMBER #16 St. James Place g t0a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ✓ 0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown 0 Ob. NAME OF SPOUSE (First, Marietta Mason Be. APT. NO. 9f. Zip CODE l 9q 1N3l.E CITY LIMITS 68803 I j YES No Middle, Last, Suffix) If wife, give maiden name .. 11. FATogir$ NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) , Arlo Beazley Roma Ellen Smith 13. EVER (N U,E, ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 08/12/1953-12/31/1954 14a. INFORMANT -NAME Marietta Beazley 14b. RELATIONSHIP TO DECEDENT'' Spouse 15. METHOD OF DISPOSITION 1.-1 Burial ❑Donation ;] Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.): January 20, 2021: 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a.:FUNERAL :HOME NAME:AND MA LING ADDRESS (Street, City or Town, State) i' ll Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code:, 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I dlseaseorconditlon resaaing:. In death) respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE tFaral a) Respiratory Failure Sequentially list conditions, if any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: b)Choroid Melanoma With No Known Metastasis DUE TO, OR AS A CONSEQUENCE OF: Eller tiro UNDERt:YINGCAUSE C) Chronic Systolic Heart Failure (disease or injurythat initiated the events resulting in death) LAST APPROXIMATE INTERVAL onset to death Immediate onset to death Years onset to death Years DUE TO, OR AS A CONSEQUENCE OF: d)Chronic Lung Disease onset to death Years 18. PARTE. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hospice Care And Died At Home 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?: ❑ YES ENO ,20. IF FEMALE: ;. ❑ Not prggnant wlthia pail year ❑• Pregnant at time of death; 0 •Nat pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ©?Unknown )?pregnant within the past year 22e ::DATE OF INJURY (Mo ; Day, Yr.) 22d. INJURY AT WORK? 0 YES.,, 0 NO 22f, LOCATION OF €NJU 21a. MANNER OF DEATH E Natural ❑ Homicide O Accident 0 Pending Investigation ❑ Suicide 0 Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES fiq NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0. NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED RY! STREET & NUMBER, APT.NO. CITY/TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) January 14, 2021 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH January 20, 2021 11:24 PM 23d. To the bast (Amy knowledge, death occurred at the time, date and place end due to. the cause(s) stated. (Signature and Title) Michael A. Donner, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP GOD 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e, On the basis of examination and/or investige ion, in my opinion de4Mto4curred at the time, date and place and due to the cause(s) stated. (Signature Itnd Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? al YES ❑ NO ❑ PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO © YES pittio .: 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 20, 2021 GD 0, C co I c...) Imo'.