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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />TRUE COPY OF THE ORIGINAL RECORD ON FILE VVITif 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 />2/2/2022
<br />LINCOLN, NEBRASKA
<br />20220%':v+
<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 01230
<br />1. p, ECEDENT`S-NAME (First, Middle, Last, Suffix)
<br />Ntyrna Lois Frlt key
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mb., Day; Yr.)
<br />January 19, 2022'.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />D:pnipha n,..Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-38.67 89
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />re
<br />r
<br />2
<br />m
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.:f3TREET AND NUMBER
<br />220E Plum Street
<br />9b. COUNTY
<br />Hall
<br />88
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea, PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ERJOu patient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated E] Widowed 0 Divorced 0 Unknown
<br />11 FATHER S NAME (First, '%Middle, Last, Suffix)
<br />Thomas Floyd Stevenson
<br />13. EVERiN LES: ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 14, 1,933
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />Hosp(ce Fac(i)ty
<br />9g. INSIDE CITY OMITS.
<br />YES Q NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Vearl D Frickey
<br />14a. INFORMANT -NAME
<br />Joel Frickey
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Irene Louise Conrad
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. M..:ETHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />Cremation © Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Stater,
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1537
<br />CITY /TOWN
<br />Doniphan
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. 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 />IAreS4EDiaTE CAUSE (Final
<br />disaese di condkbn resuftinq '
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />online a. .
<br />Enttt:the. UNDERLYING CAUSE
<br />(disease'br injury Iritt)ated
<br />a) Respiratory arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Malignant pericardial effusion
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />the events resulting in death) : DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)..
<br />10. PART it, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting; in the underlying cause given in PART I.
<br />Bilateral pleural effusions, multiple bilateral pulmonary emboli, lung mass, mediastinal and left hilar nodal spread of disease
<br />16e. DATE (Mo., Day,;Yr
<br />January'29 2022
<br />STATE
<br />Nebraska
<br />17b. Zip:Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset:* death
<br />01/19/2022 •
<br />onset to death
<br />2 Years
<br />19. WAS MEDICAL' EXAMINER
<br />OR CORONER:CONTACTED?
<br />El YES ®NO
<br />20. IF:: FEMALE:;
<br />Not pregnant within past year, .
<br />Pregnane at,time of deadi
<br />D;
<br />❑;'Not pregnant; but pregnant Within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ „Unknown if
<br />if•rorygnent within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ONO
<br />22a4)ATE OF INJURY (Ma3 Day, Yr.)
<br />re
<br />E
<br />M
<br />r
<br />• 4.c.;1''
<br />a 2,w
<br />22d. INJURY AT WORK?
<br />OYES .;:❑ NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spee)f0
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION` OF INJURY .;= STREET & NUMBER, APT.NO.
<br />a
<br />•
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 19, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 2.1, 2022
<br />Cm/TOWN
<br />23c. TIME OF DEATH
<br />03:41 PM
<br />23d. ToYhe best of my;knowledge, death occurred at the time, date and place
<br />and duetatttscause(s) stated. (Signature and Title)
<br />Jose Balo, APRN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP:CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death assured et
<br />the time, date and place and due to the cause(s) stated. (Signature and Thiel
<br />25. pID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES © NO ❑ PROBABLY ®UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 55 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ' Q.
<br />❑ NO'
<br />27 NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jose Bajo, APRN, 3533 Prairieview, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />8a -/Ler7
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 1, 2022
<br />
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