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Ill/ ,�.".:;i0011111/0,t$Ii4ODA 0ESII,;rR�'t�'tt IIID a lei $ 3 �tiVISN,IVEIg0,04§ anikaw` 2 <br />STATE (1F NEBRASKA• <br />v4.IttaN la?? : tf2t4,i4y,MxY 1ttt44itl ifttKs .- �Miy11M� <br />Ir �,2 D>'� 45YllIl 1 1A a I >�ttyJJusr \ � _: <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 <br />0 <br />d <br />E <br />4, <br />M <br />:2 <br />r <br />202105439 <br />. 7ket• I n_�iu. <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 />