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witioninimof---
<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 />DATE OF ISSUANCE
<br />3/11/2022''
<br />LINCOLN, NEBRASKA
<br />20220239
<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 />22 03501
<br />1. ;i pEDENT<$KNAME ;(First, Middle, Last, Suffix)
<br />Patty Jean Marsh
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Nie., Day, Yr,),
<br />February 19, 2022
<br />4. CITY AND S'T'ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Giltner, Nebraska.
<br />5a. AGE - Last Birthday'
<br />(Yrs.)
<br />77
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH'(Mo., Day, Yr..)
<br />7. SOCIA(SECURITY iiUMBER'
<br />505-524838
<br />8b. FACILITY -NAME (((not Institution, give street and number)
<br />510 South'. Woodland Drive
<br />8c.:CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Isiand 88801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />d. STREET AND NUMBER
<br />510 South Woodland Drive
<br />9b. COUNTY
<br />Hall
<br />toe. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First,
<br />Robert Hawthorne
<br />MIddle, Last, Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISP.oSITION
<br />au Burial ;; ❑ Donation
<br />©: Crematloil ❑ Entombment
<br />[ Removai : ❑ Other (Specify)
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑'Inpatient
<br />❑ ER/Ou patient
<br />O DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />October 21, 1944
<br />OTHER 0 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 />68801
<br />❑ Hospice Facility
<br />9g IN pE CITY l; MITS:'
<br />YEs ❑ No :'
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Ivan Gale Marsh
<br />14a. INFORMANT -NAME°
<br />Ivan Gale Marsh
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Phillips Cemetery
<br />17a. FUNERAL Home NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />12. MOTHER'S•NAME (First,
<br />Dorothy Renard
<br />16b. LICENSE NO.
<br />Middle, Maiden Sumame)
<br />CITY / TOWN
<br />Phillips
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day,,yr )
<br />February 21, 2..022
<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 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 />IMI DIA1EeAustaFlnat a) FAILURE TO THRIVE
<br />disesse or condition resulting
<br />In death)
<br />Sequentially list conditions, If
<br />any, leading to the: cause.: listed
<br />On line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)CHRONIC RENAL FAILURE
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EntertheUNDERLYING.CAUSE C) CHRONIC DIASTOLIC HEART FAILURE
<br />(disease or injury 'that initiated
<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 1.
<br />RENALTRANSPLANT
<br />20. IF FEMALE:
<br />❑❑ Pregnant s.:..
<br />Notpregnantwithlnpastyear
<br />t time of death ;•
<br />❑'Not
<br />pregnani, but pregnant within 42days of death.
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown Ifpregnent within the past year
<br />`22a. DATE OFiNJURY(Mo pay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />22b. TIME OF
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />E. Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />STATE
<br />• Nebraska
<br />1Ta. Zip
<br />8680
<br />APPROXIMATE INTERVAL
<br />onset to death:;
<br />3 Months
<br />onset to death
<br />Chronic
<br />onset tadeath
<br />Chronio
<br />onset to death
<br />19. WAS MEI:3cm,EXAM(NER::
<br />OR CORONER.CONTACTED7
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />O YES laNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH? ❑
<br />❑ YES NO
<br />22c. PLACEOF )NJURY 4t home, farm, street, factory, office building, construction site, etc. ($
<br />22e.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2f. LQCATION QF INJURY; -STREET & NUMBER, APT.NO.
<br />O a
<br />H w
<br />}o
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 19, 2022
<br />cITYrtOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 3 2022
<br />23c. TIME OF DEATH
<br />02:44 AM
<br />3d TO ((te beatot my knowledge, death occurred at the time, date and place
<br />anit tlue to the nause(s) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />2 w
<br />U �
<br />8 8
<br />25. DID TQBACCQ USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME. Il1r4E«AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan'D Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />eciry)
<br />P COBE
<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 oceUVied at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES I NO
<br />_-2,2-11
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES . ❑ NO:
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />March 8, 2022
<br />1
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