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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/6/2021
<br />LINCOLN, NEBRASKA
<br />202200197
<br />_ )6/-1 cl?Az i4
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Venus Berniece ' McShannon
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Paul, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-44.3207
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER..
<br />1112 E. OklahOrna Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Robert Brown
<br />13. EVER IN U.S,, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />0 Burial Q Donation
<br />I cremation©Entombment
<br />❑ Removal ❑ Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 16391
<br />3. DATE OF DEATH (Mo., Day, w4
<br />November 23, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr)
<br />February 26, 1941
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />eg. INSIDE CITY LIMITS;
<br />NO •
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Gary Dean McShannon
<br />12. MOTHER'S.NAME (First, Middle, Maiden Surname)
<br />Alma < Broeckemeier
<br />14a. INFORMANT -NAME
<br />Gary Dean McShannon
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART). Enter the chain of events- diseases, injuries, or complications4hat 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 />IMMEDIATE CAUSE (Final a) Septic shock
<br />disease or condition resuaing
<br />in death)
<br />Sequentially 1st conditions, if
<br />any, leading to the cause listed
<br />on lbw a.
<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)Escherichia coli bacteremia
<br />14b. RELATIONSHIP TO DECENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />November 24, 2021
<br />STATE
<br />Nebraska
<br />17b. Zip Code:.,
<br />68801
<br />APPROXIMATE INTERVAL
<br />onsetto death.
<br />Days
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Myelodysplastic syndrome, Idiopathic refractory sideroblastic anemia, Chronic myeloid leukemia, Refractory anemia with
<br />sideroblasts, Paroxysmal atrial fibrillation, Pancytopenia, Vitamin D Deficiency, Spinal Stenosis of Lumbar and Cervical
<br />20. IF FEMALE;
<br />Q Net pregnant within pest year
<br />Pregnant at tam► 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 If pregnant within the past year
<br />22a. DATE OF INJURYIMo Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Nature! ❑ Homitlde
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Q Driver/Operator
<br />Passenger
<br />Q Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />19. was MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ENO
<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, eta. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN
<br />a.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 23, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November: 23, 2021 12:38 AM
<br />d, To the beet of my knowledge, death occurred at the time, date and place
<br />end due led* a use(s) stated. (Signature and Tkk)
<br />Kimberly A. Mickels, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES E NO 0 PROBABLY 0 UNKNOWN
<br />'27. NAME, TITtg AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH'"
<br />P CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the boils of examination and/or Investigation, In my opinion death-0404tfr.d at
<br />the dine, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO ❑ YES .Q NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 2, 2021
<br />
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