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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 />6/17/2021
<br />LINCOLN, NEBRASKA
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<br />SARAH BOHNENKAMP
<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 />I. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Betty Jean Merkel
<br />2. SEX
<br />Female
<br />18 08037
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mobridge, South Dakota
<br />7. SOCIAL SECURITY NUMBER
<br />504-54-5902';
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Westfield Quality Care
<br />72
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Si. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />December 14, 1945
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) COUNTY OF DEATH
<br />Aurora 68818 18d.
<br />Hamilton
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />Hospice Facility
<br />8d. STREET AND NUMBER
<br />815NHoward
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g, INSIDE CITY LIMITS
<br />'.121.ifts ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Eugene Merkel
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Henry Speidel Lydia Hertel
<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 />Eugene Merkel
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />16c. DATE (Mo., Day, Yr.)
<br />June 20, 2018
<br />STATE:'
<br />Nebraska
<br />17e. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one Tina. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cachexia/Malnutrition (Wouldn't Eat)
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line e.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injurythat initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)CKD Stage 3
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Diabetes Mellitus II
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />None
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />for notice Which may
<br />18. PARTIL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the Underlying cause given In PART I.
<br />COPD, C. Diff, Erysipelas, CAD, PAD, Anemia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />Id!;1Not pregnant within past year
<br />❑ Pregnant et time: of 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 />0 Unknown it pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑.. Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<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 />22d. INJURY AT WORK?
<br />ri YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2018
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 18, 2018.
<br />23c. TIME OF DEATH
<br />10:08 AM
<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 />Jeff Muilenburg, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO El PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE .AND ADDItESS OF CERTIFIER (Type or Print
<br />Jeff Muilenburg, MD, 609 O Street, Aurora, Nebraska, 68818
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<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 piece and due to the causes) stated. (Signature and 'lute)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 25, 2018
<br />
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