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<br />STATE OF NEBRASKA ) ),,,,,;
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<br />WHEN 7-1413 COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TI DE COPY OF TIDE ORIGINAL RECORD ON FILE WITH TILE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE.OFoSt/ANCE.
<br />7/32022
<br />LINCOLN, NEBRASKA.
<br />202206498
<br />);SAH f�
<br />RABOHNENKAMP
<br />fit
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />4
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Qgge NT', NAME (First, Middle, Last, Suffix)
<br />eIVITT Desert Sens
<br />CERTIFICATE OF DEATH
<br />4. CITY ANI) STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska`:
<br />9: SOCIAL SECt#RITY N MBER
<br />SO8-4S 2099
<br />8b. FACILITY -NAME (If not institution; give street and number)
<br />1:11•Mernp)1ts PIaC
<br />Bc;OETY OR TOWN OF DEATH (Include Zip Code)
<br />,Grand Island 68803
<br />9a.RESIDENCE-STATE
<br />Nebraska ..
<br />9d.'sTREET AiViS NUMBLi2
<br />3411 Memphis Place
<br />8kAGE Lest Sirthdat
<br />(Yre)
<br />80
<br />813. UN ER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a..PLACE OF.DEATH
<br />HOSPITAL D] inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />MARWALSThTUS ATTIME OF•DEATH ®'Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />F74THER'SIAME tFlrtt£ Mld€ile, Last,
<br />Darrow A elvtn wits
<br />Suffix)°
<br />k3,'EYfaR IN U.S..ARMED FORCES?'Give dates of service If Yes.
<br />(Yes, No, or Unk) Yes 02/28/1966-02/01/1968
<br />ETHOD OF. ptStaOSITION
<br />.Surrat. Donation
<br />Cremation:: ❑Etttotnhment
<br />unoval :i Other pecify).
<br />A•
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAN {Mo., Day;
<br />June 17, 2022
<br />G. DATE OF BIRTH (Mo., Day,' n}
<br />Au lust 10::1.
<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 />10b. NAME OF SPOUSE (First, Middle,
<br />Marlys Diana Christensen
<br />12. MOTHER'S -NAME (First, Middle,'
<br />Maxine Liedtke
<br />ce FltrA lty
<br />9f. ZIP CODE
<br />68803
<br />Last, Suffix) if wife, give t1u(Iden
<br />14a. INFORMANT -NAME
<br />Marlys Diana Sems
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1eb. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL: HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All faiths Funeral l4ome, 2929 S. Locust Street, Grand Island,, Nebraska
<br />CAUSE OF DEA
<br />4$, P SIDE COY t i1V�rTs
<br />(I� YHSiO
<br />14b: RELATIONS
<br />Spouse
<br />1Sc,D
<br />ATE (o
<br />June 18, 21:;
<br />(See ifstruotions and examples)
<br />Nebraska
<br />iib.Ytp4+
<br />S880I
<br />ART I. Enter the di*in of events- -Manages, Injuries, or complicationsdhat directly caused the death.: DO NOT enter terminal events such as cardiac arrest,
<br />rasplratory arrest,or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />Au (Fl.4 :: a) acute on chronic systolic congestive heart failure
<br />0n00i in ra00.(gr,C,-
<br />at.d0119)
<br />Sequentially list conditions, If
<br />any,,ieadtnp to tht;Cahrt p,t.t •.
<br />onih4a
<br />Emiktm. r tNdstRllYINQ PIU
<br />(d+aeeae dr in)ury' hat Ir9titte
<br />the avents resulting in death)'
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) ischemic cardiomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) myocardial infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)severe coronary artery disease
<br />18. #ART 11 OTHER StGPNFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />ventrlcuter taehyoardia, hypertension, hyperlipidemia, Obstructive sleep apnea, cfrronic obstructive pulmonary disease,
<br />20. IF.fEMALE
<br />{{^^�� Not ptagnent.within pest ye . .
<br />Rregnatd et unte ofdeaar
<br />Not prsgnardr�� pregnant within 42 days of death
<br />Not pregnant "but pregnant tit rr�-� dayesto'1' yeaefore death
<br />Unknown a:pregnam asat)n the past year b
<br />2
<br />ATE.OF INUII.Y (Mo y; Day, Yr.)
<br />INJURY AT WORK? I.
<br />©YES ❑NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homiatde
<br />0 Accident 0 Pending Invegti
<br />0 Suicide 0 could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />22e. DESCRIBE HOW INJURY; OCCURRED
<br />LOCATION 'OP INJURY:;:: STREI
<br />8. NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2022
<br />OF IN,
<br />RYAt h
<br />21b. IF TRANSPORTATION INJURY
<br />Et Ortrrer/Operator
<br />0 PAssenger
<br />❑ Pedestnan
<br />❑ Other (Specify)
<br />19. WAS MEDICAL::EXAMINER::;::.
<br />ER
<br />OR C R�:CONTA Sb
<br />❑ Yes ISI NO .
<br />21c. WAS AN AUTOPSY. PERPORM f}T.
<br />❑ YES'
<br />21d. WERE AUTOPSY FINDINGS A11AfLABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N ... ...
<br />e„farm, street, factory, office building, construction siterti
<br />CITY/TOWN.'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Jiang 2S, 202 04:04 AM
<br />tt.1`rf ttie pe4 Of 4ty knowledge, death occurred at the time, date and place
<br />SW note Mia squeals) stated. (Signature and Title)
<br />!ay C. Anderson, MO
<br />STATE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAI)1, :.,..
<br />24n. On the bests of examination and/or investigation, In my opinion deathitn tlnedat
<br />the fine,, date and place and due to the cause(s) stated. (Signature and ?lik)..
<br />28 DID roBAGQO USECONTRIBUTE TO THE DEATH?
<br />YES NO "PROBABLY 0 UNKNOWN
<br />27. t4.ME,'f) .... ANb!A...._ ESS OF CERTIFIER (Type or Print
<br />satp, Anderson, RAD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E•1
<br />26b. WAS CONSENT GRANTS0?
<br />Not Applicable if 26a Is NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)'
<br />June 28, 2022
<br />
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