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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 OFISSUANCE
<br />3/22/2021
<br />LINCOLN, NEBRASKA
<br />202105744,
<br />'itji ..1.54/146,42.,e4t kf.
<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 />21 03492
<br />1.
<br />DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William Robert Marsh MD
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Y:)
<br />March 12, 2021 ;.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />72
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH: (Mo., Day, Yr.)
<br />April24, 1948
<br />7. SOCIAL SECURITY' NUMBER
<br />507.66-2651
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />Grand Island Country House, L.L.C.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (SpecitY)ASSISTED LIVING
<br />0 Hospice Faclkty
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d, STREET AND NUMBER
<br />2204 South Blaine Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LI!MITS'<
<br />® YES 0140
<br />10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Annabelle Brodbeck
<br />11. FATHER'S -NAME
<br />William Warre
<br />(First, MIddle, Last, Suffix)
<br />n Marsh
<br />I12. MOTHER'S -NAME (First,
<br />Virginia Peters
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMEDFORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />14a. INFORMANT -NAME
<br />Annabelle Marsh
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑"Burial ❑ Donation
<br />} Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />March 16, 2021 ;.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<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 />CAUSE OF DEATH (See instructions and examples)
<br />13. 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 on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATecame (Final a/ Respiratory Failure
<br />a*q se orConditionrepotting
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Parkinsons With Dementia
<br />17b. ZIP Coda..
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 1 Week
<br />onset to death
<br />> 1 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Inlwythat initiated
<br />onset to death
<br />the events resuitinp in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PARTE, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not res
<br />)ting'; in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER. CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE:.:
<br />❑ :Not pregnant within past year
<br />0 Pregnant at 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 beton death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 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 0 NO
<br />22a. DATE OF INJURY (Mo Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />arm, street, factory, office building, construction site,' etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES ❑NO:.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22(, LOCA TION:OF INJURY:; STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 12, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mart 1 202
<br />23c. TIME OF DEATH
<br />06:03 PM
<br />234. To the best of my knowledge, death occurred at the time, date and place
<br />ami due to the cause(s) stated. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO ❑ PROBABLY 0 UNKNOWN
<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 />thetime, date and place and due to the cause(s) stated. (Signature and Tale)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES
<br />CI N
<br />27. NAME, TITLE: AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 8
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 18, 2021
<br />1
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