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<br />STATE OF NEBRASKA
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<br />I 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 />12/10/2021
<br />LINCOLN, NEBRASKA
<br />2022.00544
<br />I a +
<br />)IAS IIIc 11- d' 4y:E4NLKAilkIt:Py
<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 />. DECEDENTS.NAME (Ftret, Middle, Last, Suffix)
<br />Lauren Kaye Stevens
<br />2. SEX
<br />Female
<br />21 15381
<br />3. DATE OF DEATH (Mo., Day, Yr},
<br />November 10, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-88-8771
<br />5a. AGE - Last Birthday'
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />315 N. Grace Ave
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />lt. FATHER'S'NAME (F)rst, Middle, Last, Suffix)
<br />Robert Martin
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />75
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF, DEATH
<br />HOSPITAL J Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 10, 1946
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />CI Hospice Facility
<br />9p.NI
<br />CITYUMITS
<br />NI YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Darrell Stevens
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ilene Bishop
<br />14a. INFORMANT -NAME
<br />Sherri Kolar-Reisbeck
<br />14b. RELATIONSHIP TO DECEDENT''
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />El Cremation ❑ Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />November 11, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />175. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for
<br />Other (Specify)...:
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- 4Neases, injuries, or compltcatlonslhat directly caused the death. DO NOT anter 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 lints If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEOIATECAU$E(Final -:: a) Aspiration Pneumonia
<br />disease or condition resulting
<br />Sequentially list conditions, H
<br />any, leading to the Cause listed
<br />on 1100..
<br />Enter She UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />17b. Zip code
<br />68601
<br />APPROXIMATE INTERVAL
<br />onset to death:
<br />Days,:
<br />onset to death
<br />onset b*Meibtfi
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resultingin the underlying cause given in PART I.
<br />20. IF FEMALE
<br />® Not pregnarnwithin past year
<br />0 Pregnant aroma a death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />O Not pregnant, but pregnant 49 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />22a, DATE
<br />F INJUR( 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 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />© Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />19. WAS MEDICAL EXAMINBRi;:
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<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 INJURYAt home, ferm, 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 />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 10, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 11, 2021 05:14 PM
<br />22d. To the best of my; knowledge, death occurred at the time, date end plan
<br />end due to the cause(s) stated. (Signature and Title)
<br />Nicole Anderson Ericksen, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
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<br />Uz
<br />W
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<br />26a. HAS ORGAN OR SSUE DO
<br />❑ YES E7 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Nicote Anderson Ericksen, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24.. On the basis of examination and/or investiga Ion, In my opinion death osourred Car
<br />the tint., date and place and due to the cause(s) stated. (Signature and TUN)
<br />ATIONBEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES . 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 15, 2021
<br />
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