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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 />'4UMAN'+SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />;DATE OF ISSUANCE
<br />12/3/2021
<br />LINCOLN, NEBRASKA
<br />202202043$''
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Mary Jane Frances Lee
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Davenport, Iowa
<br />7. SOCIAL SECURITY N)M.BER
<br />480-32-3387 ..
<br />8b. FACILITY -NAME (If ntft Institution, give street and number)
<br />508 White Avenue
<br />8c,.CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ed. STREET AND NUMBER.
<br />508 White Avenue
<br />9b. COUNTY
<br />Hall
<br />10a.'MARITAL STATUSATTIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated El Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First,
<br />•
<br />Walter Hermes
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />O. PLACE OF DEATH
<br />• HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo.', Day Yi )
<br />November 11, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.) ..
<br />April 23, 1932
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />pice Facility
<br />•
<br />9q INS(OE CITY L(MIT$
<br />10b. NAME OF SPOUSE (First, ' Middle, Last, Suffix) If wife, give maiden name
<br />Robert E Lee
<br />Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ij Mabel Tobin
<br />13. EVER IN U.LARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />Burial ❑Donation
<br />❑;;Cremation ❑ Entombment
<br />❑'Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Mary Lee
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL,HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT eider 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 />a)COVID 19 infection
<br />IMMEDIATE CAUSE (Finer„
<br />disease orconditioq resuarng
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />,On line a.
<br />EgfE the UN©EW1NO CAUSE
<br />(dis(qse or injury that inffWte i
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Type 2 diabetes, morbid obesity
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP TO O
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />November 19, 201
<br />CEDEN'E.
<br />S rATE
<br />Nebraska
<br />17b. Zip Code
<br />fi881
<br />APPROXIMATE INTERVAL
<br />onset to death::
<br />8 Days
<br />onset to death
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />advanced dementia (78 to 7C on Hospice admission). Patient with Advance Directive directing no hospitalization, comfort cares
<br />only
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEa7
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />1:11:1P"
<br />:Not pregnant within past year
<br />Rregnant ei time o1 death
<br />El Not ptegnam, but pregnant within 42 days of death
<br />❑ Not,pregnant, but pregnant 43 days. to 1 year before death
<br />❑ Unknown If. pregnant within the past year
<br />22a. :ATE OF
<br />NIURY(Mo; :Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Dnwer/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES
<br />® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ vas ❑ No
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify).i
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />a
<br />0
<br />H
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 11, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />NOvember:26, 2021
<br />23c. TIME OF DEATH
<br />Unknown
<br />8d, Tp;Iia best of my;knowledge, death occurred at the time, date and place
<br />and duetethetatiee(s) stated. (Signature and Title)
<br />Michelle D Schiel, APRN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ,.2 NO ❑;PROBABLY ,❑ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />240. OP the basis of examination and/or investigation, in my opinion death Uccarred at
<br />the time,date and place and due to the causeis) stated. (Signature and idle)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Idl NO
<br />7.:NAMEr TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Michelle D SC)tiel, APRN, 1201 Allen Dr Ste 163, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES; 0 NO
<br />28a. REGISTRAR'S SIGNATURE j
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 30, 2021
<br />01
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