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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 />202100705
<br />DATE OFISSUANCE
<br />12/3/2018
<br />LINCOLN NEBRASKA
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND 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 />Sandra Edna Patzer
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dickinson, North Dakota
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />71
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 27, 2018
<br />6. DATE OF BIRTH (Mo., Day, Yr:)
<br />March 19, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />502-50-5748
<br />Q 9b. FACILITY -NAME (if net Institution, give street and number)
<br />rit • Mary tanning Healthcare
<br />d
<br />5 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />% Hastings 68901 .
<br />1 9a. RESIDENCE -STATE 9b. COUNTY
<br />1 Nebraska Hall
<br />9d. STREET AND NUMBER
<br />1 • 2403 West Koenig
<br />t 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />13 z ❑ Married, but separated ° ❑ Widowed 0 Divorced 0 Unknown
<br />er 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Gerald Provolt
<br />• '3 EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) NO
<br />▪ 15. METHOD OF DISPOSITION
<br />g❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other(Specify)
<br />is
<br />8
<br />8a. PLACE OF DEATH
<br />HOSPITAL® Inpatient
<br />ER/Outpatient
<br />❑ OOA
<br />9e. CITY OR TOWN
<br />Grand island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Adams
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />66803
<br />Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />1Ob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name
<br />Donald Edward Louie Patzer
<br />12. MOTHER'S -NAME (First, Middle,
<br />Gladys Newby
<br />14a. INFORMANT -NAME
<br />Donald Edward Louie Patzer
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />November 28, 2018
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY I TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />14, PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enterlarminal events such ascardiac arrest,
<br />* respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tinea Add additional lines if necessary.
<br />I IMMEDIATE CAUSE:
<br />t IMMEDIATE CAUSE (Final
<br />a disease or condition resulting
<br />m ..
<br />m
<br />5
<br />m
<br />fii:desth)
<br />Sequent al t get conditions. d
<br />any, leading to tie cause Listed
<br />.Enter the. UNDERLYING CAUSE
<br />,Idiseittieer Injurytttet lnitiated
<br />ted events resuIt.na. In death)
<br />a) Septic Shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I?) Clostridium Sordellii Bacteremia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Perforated Colon
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Metastatic Colon Cancer
<br />APPROXIMATE INTERVAL
<br />onset to death ..
<br />48 Hours
<br />casctto-so*
<br />48 Hours
<br />onset to death
<br />48 Hours
<br />onset to death
<br />1 Year
<br />11,,
<br />IF FEMALE:
<br />• ® Not pregnant with n past year
<br />. ❑ Pregnant at time of death
<br />•3E 0 Not pregnant, but pregnant within 42 days of death
<br />8 0 Not pregnant, but pregnant 43 days to 1 year before death
<br />I0 -Unknown if pmgnates/Rhin the past year
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />Severe Protein Calprie Malnutrition OR CORONER CONTACTED?
<br />❑ YES NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />(3
<br />O
<br />1 n
<br />E w
<br />IR
<br />2 u
<br />O
<br />a E g
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Inveatigaaon
<br />❑ Suicide ❑ Could hot a 4etermNed
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Diver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOFSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE of DEATH?
<br />❑YES No
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 27, 2018
<br />CITY/TOWN
<br />iib. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 28, 2018 08:44 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Tito)
<br />Caitlin S. Foxley, MO
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH(
<br />24d. TIME PRO+JOUNC€D DEAD
<br />gg
<br />, s 24e. On the basis of examination and/or Investig tion, M my opinion teeth occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and TdI).._
<br />25. DID TOBACCO UCECDNTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE' DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print-
<br />fOxleWiLMD, 715 N St Joseph, Hastings, Nebraska, 68901
<br />. REGISTRAR'SSIQNATURE
<br />laaia
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTPAR tE1o., Day, Vi.)
<br />November 30, 2018
<br />
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