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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V)TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE.AN E
<br />2f; t2o
<br />LINCOLN, NEBRASKA
<br />Amended
<br />a
<br />8
<br />a
<br />202203326
<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 />. D! ECEp.NT`.$-NAME. (First, moiki., Last, Suffix)
<br />G8rolyn ;Jest Davis
<br />4. (IMAM STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Merrick County,.; Nebraska
<br />7 SOCIAL SECURITY NUMBER
<br />508.441372
<br />8b. FACILITY-NAME{tf Not inste,uflooi,give street and number)
<br />3004 Westskie Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />+rand lsterrd 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />SILAGE - Last Hlrthday db. UNDER 1 YEAR
<br />(Yre.)
<br />84
<br />MOS.
<br />DAYS
<br />tla PLACE OF DEATH
<br />HO$PtTAL 0 inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9d. sTREETai)D N(IMOOI
<br />104 Westside Street
<br />los. MARITAL :STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Marded, but separated ® Widowed 0 Divorced 0 Unknown
<br />1. FATNacree? ME (First, Middle, Last, Suffix)
<br />Thornes Cot)de11
<br />13. EVI .IN.U4S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, prink.) No
<br />15. METiIOD`QF DISPOSITION
<br />Burial j Donation
<br />Crematlo i [,Entombment
<br />Q RemovaI ;' Q Other (Specify)
<br />68. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH.:(Mo pay, Yr.)
<br />December 12, 2041
<br />8. DATE OF BIRTH (Mo., Day, Yt.)
<br />OBER LJ Nursing Home/LT
<br />611 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />8e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Arthur
<br />9f. ZIP CODE
<br />68803
<br />Suffix) If wife, give m
<br />Davis
<br />1 12. MOTHER'S.NAME (First, Middle,
<br />Esther Scarborough
<br />14a. INFORMANT•NAME
<br />Beverly Stutzman
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Rose Hill Cemetery
<br />16b. LICENSE NO.
<br />1328
<br />Maiden Surname)
<br />CITY I TOWN
<br />Palmer
<br />14b. RELATI
<br />Daughter
<br />16c. DATEt1Yft
<br />Ded
<br />17a, FUNERAL:HOMENAME AND MAIUNG ADDRESS (Street, City or Tower State)
<br />Greenwav-Dietz Funeral Home, 802 Templin, Palmer, Nebraska'
<br />Nebraska l
<br />fib. Zip Code
<br />88864
<br />CAUSE QF DEATH (SOiCiriStrttationts arid examples)
<br />18. PART I. Ent4r tI» chain of events- diseases; Injuries,'or eompgcationsdhat directly caused the death. DONOT enter terminal events such as cardiac arrest,
<br />respvatory arrest, or ventrkutar f bdtlatiali without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a dna. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Liver Failure
<br />IbleNDIATE CAN,SE (Finer
<br />dteeese orcondition re Ut6np;
<br />trainer)
<br />Sequentially ilst conditions, If
<br />any, Waging tog* cauee:pated
<br />online a
<br />Elket tits tBIOEda. fINtt t AUBtt
<br />(d aaese or If4urythet h tri tad'
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Non-Alcohol related Cirrhosis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />APP, ATE 'INT ERVA
<br />otise,t4tdohlth
<br />MOBBISAP
<br />onset todeath
<br />Months
<br />18. PART N. OTHER StoromANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Spontaneous Bacterial Peritonitis and Esophageal Varices
<br />20. !FFEMALE
<br />Not pregntiiit wtth3n pest yae
<br />Pregnsetatthne of deaet
<br />❑--NA1 ptegnsrir, lurt pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />1:1,:l#WrIgartl1fPtegnenkurithIn the past year
<br />22a.. ATE OF INJURY (MO.. Day, Yr.)
<br />21a. MANNER QF DEATH
<br />® Natural ❑ Hontickle
<br />Q Accident 0 Pegging IfVastgeitten
<br />Q Suicide Q Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Pasanger
<br />®'Pedestrian
<br />0 Other(Specify)
<br />22c. PLACE:OF INJURY At home;;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22d.LOCATION OF INJURY STREET'S NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 12, 2021
<br />onset to death
<br />19. WAS MEDtCtA( EXAMINER
<br />OR coNoNsecoNTAcTacer
<br />❑ YES NO
<br />21c. WAS AN AUT4PSY PERFORM...ED?
<br />❑ YES.e((}
<br />21d. WERE AUTOPSYF#NONGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />nn, street, factory, office building, construction sea etC (S)ft?)
<br />CITYPrI
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />DecetTser:16.2021 05:50 PM
<br />Tt.the Itis of my knowledge, death occurred at the time, date and place
<br />and dwtoths'.eause(s) stated. (Signature and Tice)'
<br />Chad Vieth, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c.. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD .
<br />•245 0n the basis of examination and/or investigation, h my opfnt¢h, death daturred at
<br />::the time, dote and place and due to the cause(s)stated. (BIRJattHattnd'ftte); ...
<br />26 D.lp TOBACCO USE C ONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR 11SSU. E DONATION::BEEN CONSIDERED?
<br />2t -
<br />YES :❑ NO 0 PROBABLY ® UNKNOWN ❑ YES NO
<br />.NAME, "t1; f .E AND ADA ESS OF CERTIFIER (Type or Print
<br />Chats Vieth, MD, 2118 W Faidley#400, Box 9802, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES r �i Nl7
<br />28b. DATE FILED BY REE
<br />January 4, 2022
<br />18, Part 1 a) Lung Cancer To Liver Failure, b) Blank Added Condition
<br />18 Part 11 Chronic Obstructive Pulmonary Disease, CAD; Congestive Heart Failure To, Spontaneous Bacterial Peritonitis And Esophageal Vatices
<br />Mara 23c 1>1:21PM To 5 50PM
<br />
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