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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 />8/26/2021
<br />LINCOLN, NEBRASKA
<br />2021093'rt
<br />a a `/r2 ,t) < d ./1. i'i ,e1. r.
<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 10523
<br />d
<br />E
<br />d
<br />E.
<br />0
<br />0
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marcella !LouiseDerrickson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 10, 2021
<br />Shelton, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />506-28,7911
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If -not Institution, give street and number)
<br />Good Samaritan Societv-Grand Island Village
<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 />93
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day,Yr.)
<br />August 4.,:1928
<br />OTHER E Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Hoeptce Facility
<br />9d. STREET AND NUMBER
<br />311 E. South St
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INS DE CITY UNITS
<br />®YES 0 N
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated E Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nem'`
<br />Charles Derrickson
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix)
<br />Earl Blue
<br />I12. MOTHER'S -NAME (First, Middle,
<br />Mary Thomas
<br />Maiden Surname)
<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 />Kerri Wetovick
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />Q' Burial 0 Donation
<br />E Cremation 10 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />Auqust 12, 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 />111. 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 />a) metabolic acidosis
<br />IMMEDIATE cedes (pini
<br />*tease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line*
<br />Enter the ui,i0et LYING CRUttE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute kidney injury
<br />17b. Zip Coda :.
<br />68801;
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) hypertension
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18, PARTII. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />chronte heart` failure, mitral regurgitation, Chronic kidney disease, anxiety, osteoporosis, hypothyroidism, collagenous colitis
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at Noe 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 />❑Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES J NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,: etc. IS
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22(. LOCATION OF INJU(iY STREET 8 NUMBER. APT.NO.
<br />EU Z
<br />r, o
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 10, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 11: 2021
<br />23c. TIME OF DEATH
<br />01:18 AM
<br />3d. To the beep of my knowledge, death occurred at the time, date and place
<br />end due to the cause(a) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO 0 PROBABLY E UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<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 *Mitt deeurred: et
<br />the time, date and place and due to the cause(s) stated. (Signature and Titie)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i'.1 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />L,_3
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable it 26a is NO 0 YES
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />August 13, 2021
<br />
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