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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, fT 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 />12/17/2021
<br />LINCOLN, NEBRASKA
<br />202200900
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<br />64441/4'
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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. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Mary Alice Williams
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mullen, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505.56-4186
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 7, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />8b. FACILITY -NAME III 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 />90, STREET AND NUMBER
<br />133 Ponderosa Drive
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL IJ Inpatient
<br />❑ ER/Outpatient
<br />❑DOA
<br />9c. CITY OR TOWN
<br />Grand, Island
<br />January15, 1946
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />HospiceFacility 't
<br />Be. APT. 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 />9f. ZIP CODE
<br />68803
<br />9p. INSIDB CIWUM(TE
<br />tr,iii21 YES ❑ Na ;
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donald Dean Williams
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Charles Elliott
<br />12. MOTHER'S -NAME (First,
<br />11 Evelyn Revere
<br />Middle, Maiden Surname)
<br />13:'EVER IN USS. ARMED FORCES? Give dates of service H Yea.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Donald Dean Williams
<br />15. METHOD OF DISPOSITION
<br />IE Burial ❑ Donation
<br />Cremation 0 Entombment
<br />Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />December 13. 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17e, FUNERAL HOME NAME AND MAILING 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 />18. PART I. Enter the chain of events- diseases, injuries, or complications -hat 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 (Final s.
<br />disease or condition ree rating
<br />In death)
<br />IMMEDIATE CAUSE:
<br />6) lung cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, it b)
<br />any, leading to the cause listed
<br />online a
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />the events resulting In death)
<br />LAST
<br />18, PARTtL OTFIER
<br />17b. zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<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 />GNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />20.�IF1FEMALE:
<br />El Not ptegnani within past year
<br />0 Pregndnt tit time ordeal')
<br />❑--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 It 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 />® 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 />0 Driver/operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ib1 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, eta. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 7, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 14 2021
<br />23c. TIME OF DEATH
<br />08:35 AM
<br />23d. To the best of my knowledge, death occurred at the time, date end place
<br />and due to the eause(s) stated. (Signature and Title)
<br />Travis S. Hageman, MD
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD r„
<br />24e. On the basis of examination and/or investigation, in my opinion death ooturred at
<br />the time, date and place and due to the cause(s) stated. (Signature add Tale)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ENO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO OYES : 0 NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 16, 2021
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