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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 />10/16/2020
<br />LINCOLN, NEBRASKA
<br />202110899
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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 />20 13643
<br />Pursuant to section 304413 demands for notice which may affect the estate of the deceased are filed with the county court In the county where the decedent resided at the time of death.
<br />. 1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />LXnn Michael Hetrick
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo', Day. Yr.)
<br />October 5, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, 'Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />61
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 29, 1959,
<br />7. SOCIAL SECURITY NUMBER
<br />506-84.0587
<br />8a. PLACE OF DEATH
<br />HOSPITAL C Inpatient OTHER 0 Nursing Home/LTC Q Hospice Facility
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1935 Freedom Drive
<br />Be. APT. NO.
<br />91. ZIP CODE9g,
<br />68803
<br />INSIDE CITY LIMITS
<br />Yes 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME Of SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jacqueline Bloomquist
<br />11. FATHER'S -NAME (first, Middle, Last, Suffix)
<br />Merwin P Hetrick
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ruth Kesel
<br />13. EVER IN U.8. ARMED FORCES? Give dates of service H Yea.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Jacqueline Hetrick
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />1537
<br />16c. DATE (Mo., Day, Yr.)
<br />October 8.2020
<br />Ea Cremation ❑Entombment
<br />Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL
<br />Apfel Funeral
<br />HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />19. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) metastatic small Cell Lung Cancer
<br />disease or condition resulting
<br />onset to death
<br />2 Weeks
<br />In deetn) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to Me cause listed
<br />on linea.
<br />' onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter 11w UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death'
<br />Inc events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Net pregnant within past year
<br />0 Pregnant et time of dWh
<br />21a. MANNER OF DEATH
<br />® Nature) ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operetor
<br />, ❑: Passenger
<br />21c. WAS AN AUTOPSY, PERFORMED?
<br />❑ YES _
<br />0 Not pregnant, but pregnant within 42 days of deaM❑
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown ifpregnam within Inc put year
<br />Suicide ❑Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY(Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />22d. INJURY AT WORK?
<br />OYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION:' OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />enpb:ted by
<br />CERTIFIER
<br />INLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 5, 2020
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Oct0bet 6, 2020
<br />23c. TIME OF DEATH
<br />04:19 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />13.1. To the best of my knowledge, death occurred at Inc time, date and place
<br />and due to the cause(s) stated, (Signature and Title)
<br />Ryan D. Crouch, DO
<br />24e On the basis of examination and/or investigation, in my opinion death occurred at
<br />< the time, data and place and due to the causeid s) stated. (Signature aTitle)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES' ©NO'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand
<br />Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />a.4
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 14, 2020
<br />
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