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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/10/2021
<br />LINCOLN, NEBRASKA
<br />202202298
<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 />Marilyn ;Alice Steffen
<br />d, CIM AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dannebroq, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />79.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2106008
<br />3. DATE OF DEATH (MO,. Day, Yr.
<br />Mav 2, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />7, SOCIAL SECURITY NUMBER
<br />508-54-3621
<br />8b..FACILITY-NAME ''(If 'not Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 58803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />September 22 1941
<br />OTHER E Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Hospice Faetl(ty
<br />9ds4TREETAND NUMBER
<br />2604 N St Paul .Road
<br />9e. APT. NO.
<br />98. ZIP CODE
<br />68801
<br />9g, INSIDE CITY LIMITS
<br />® YES Q NO
<br />105 MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Leland Steffen
<br />11,:FATHER'S:NAME (First, Middle, Last, Suffix)
<br />Albert Madsen
<br />12. MOTHER'S -NAME (First,
<br />Elsie Harvey
<br />Middle, Maiden Surname); .
<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 />Leland Steffen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />ED Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />Removal ❑Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />1537
<br />16c. DATE (Mo., Day, Yr.)
<br />May 8, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY /TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a.FUNERAL. HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />r
<br />ApfeFuneral Home, 1123 W. 2nd, Grand Island, Nebraska
<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 enter terminal events such as cardiac arrest,
<br />respiratory arrest, or veMncular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE OAU}SE(final a) Ovarian Cancer
<br />disease or condition tasu8htg
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading tothe cause listed
<br />on Fine a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYINGCAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />17b_;;Zip Code?:
<br />6880'[
<br />APPROXIMATE INTERVAL
<br />oneetdo death
<br />Months
<br />onset to death
<br />onsetto death` ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8.; PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART!.
<br />Breast Canter
<br />20. IF FEMALE:,
<br />QNot pregnant within past year
<br />0 +�'j
<br />Pregnant at time of death
<br />0-: Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑. Unknown if;pregnent 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 />E Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />21c. WAS AN AUTOPSY F RFORMED? ,
<br />❑ YES IJ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑ NQ:.:.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.`,LOCATI0NOF INJURY STREET & NUMBER, APT.NO.
<br />0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 2, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />MeV 61021
<br />23c. TIME OF DEATH
<br />03:05 PM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES;(] NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />(Specify)
<br />ZIP CODE •
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation,: in my opinion death occurrdst
<br />(80(800, date and place and due to the cause(a) stated. (Signature end Ile)"
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />27„NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES: N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 10, 2021
<br />
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