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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 />DA re OF ISSUANCE.
<br />11/20/2021
<br />LINCOLN, NEBRASKA
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<br />202200390
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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 />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME First, Middle, Last, Suffix)
<br />Laurie Ann Gress
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burke, South Dakota
<br />7, SOCIAL SECURITY NUMBER
<br />507-92.4438
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Nebraska Medicine
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />Si. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4128 Driftwood Dr., I;
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH IE Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />61
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />© ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 15791
<br />3. DATE OF DEATH (Mo„ Day, Yr-)
<br />November 7, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.}
<br />February 26., 1960
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803•
<br />0 Hospice Facility
<br />93.. INSIDE CITY LIMITS
<br />®..YES > .❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Wayne Gress
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Marlyn John Ludemann
<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 />Wayne Gress
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mardell Maertin
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial Q Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />18e. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo, Day, Yr.)
<br />November 12, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER. LOCATION
<br />CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />Nebraska
<br />175. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All: Faiths FOnerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. 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 />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 IFInei a) Respiratory Failure
<br />diseaseor*Mrditton'resulting
<br />In dear!,) _ DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b) Hepatic Encephalopathy
<br />pity, leading to the cause listed
<br />on lint 5.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enterttrt UNDERLYING CAUSE "c) Non-alcoholic Cirrhosis
<br />(digitate :Or;Injury that Initiated
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Months
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _. 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 />Renal Failure
<br />onset to death
<br />19. WAS MEDICAL:EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />Nat 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 H pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO_
<br />21a. MANNER OF DEATH.
<br />® Nature! 0 Homicide
<br />❑ 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 />❑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 />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 7, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 9 2021
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:36 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(*) stated. (Signature and Title)
<br />Daniel M. Hershberger, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Daniel M. Hershberger, MD, 985990 Nebraska Medical Center, Omaha, Nebraska, 68198
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24*. On the bselsof examination and/or Investigation, In my opinion death OCctilved at:
<br />the lime, date and place and due to the cause(*) stated. (Signature and Tait)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ®NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO ❑ YES 0 NO
<br />28a. REGISTRAR'S SIGNATURE --
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 16, 2021
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