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<br />STATE OF NEBRASKA
<br />e</llltllrllfflt+` rlriulrl�ll t
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF TIDE 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 />BATE OF ISSUAIf CE
<br />6/11I2Q2
<br />LINCOLN, NEBRASKA
<br />M//tr°.+°i r�rt•$°ca:$/C_-.p
<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 />Wallace. 'Orville Burrows
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doniphani; Nebraska
<br />7. SOCIAL SECURITY 38 UMBER
<br />$08738-0962,
<br />5a. AGE - Last
<br />(Yrs.)
<br />90
<br />8b. FACILITY -NAME(
<br />Institution, give street and number)
<br />Grand Island Country House, L.L.C.
<br />Sc.. -CITY OA TOWN CIF DEATH (Include Zip Code)
<br />Brand Bland .68803
<br />9a. FRESIDENCE-STAT
<br />Nebraska
<br />STREET AN NUMBER
<br />4333 prairie Clover Circle
<br />9b. COUNTY
<br />Hall
<br />rthday
<br />lib.UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER I DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a. MARITAL. STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, butseparated ❑ Widowed ❑ Divorced 0 Unknown
<br />FATHER'S -NAME (First, Middle, Last, Suffix)
<br />hflliant Reuel Burrows
<br />13. EVER DI U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit) Yes 04/01/1952-03/01/1954
<br />15.,METHOD OF DISPOSITION
<br />;'Burial ( Donation
<br />❑::Cremation: El Entombment
<br />❑`RemovaF ❑fltttOr (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (t4o., Day ,f€).
<br />May 27, 2022
<br />6. DATE OF BIRTH (Mo;1 Delo`, Tr.)
<br />August
<br />OTHER 0 Nursing Home/LTC (l
<br />0 Decedent's Home
<br />r-, Other (Specify)ASSISTED LI
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n
<br />Marjorie Macomber
<br />14a. INFORMANT -NAME
<br />16a.' EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />Marjorie Burrows
<br />9g INSIDECV(iY+yLIMITS<'
<br />12. MOTHERS -NAME (First, Middle, Maiden
<br />Ethel Lindgren
<br />16b. LICENSE NO.
<br />1071
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Giltner Cemetery
<br />a•..UNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AIS Falt'is FUrteral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />14b. RELATIO
<br />Spouse
<br />HIP TO DECEDENT:"
<br />flier DATE:(Mo., Day,.
<br />June 1, 2t22
<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 ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one rause one line.. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />HeartFailure
<br />APPROXIMATE INTERVAL
<br />set.:to.dertt
<br />IW
<br />ars .
<br />MEDIATE cause (Final a) Congestive F I
<br />disease or candition Mail 10
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Late (onset Alzheimer's Dementia
<br />any, leading to the cause gated
<br />DUE TO,,OR AS A CONSEQUENCE OF:
<br />Eelet6le UNDERI'INCDAU$E C) Sepsis
<br />(diSAese dr inJui thatiniilated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />must to deati
<br />2 Weeks
<br />PART I( OTHERSIGNIFICANT CONDITIONS -Conditions contributing to the death
<br />wt naoresu(dng In the underlying cause given In PART I.
<br />;WAS MEt»CAtLExAMINER
<br />OR CORONER CONTACTED?
<br />YES ® NO
<br />20 IF FEMALE ....
<br />Not pregnant w$hrn paatyear
<br />pregddtit at tline;af death
<br />❑ Nc4 pregnene tit pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />Unknown 8:pregnant within the past year
<br />2,
<br />DATE OF INJURY (MC Day, Yr,)
<br />E 22d. INJURY AT WORK?
<br />o
<br />13 ❑ YES ..❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 pending iMYsatigatien
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACEOF UR
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATK)N OF INJURY:. STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 27, 2022
<br />k
<br />u.
<br />F
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 3p-24)22
<br />t 80Tp lbs best of my knowledge, death occurred at the time, date and place;
<br />till) dtie 1a lite o*use(a) stated. (Signature and Title)
<br />Richard.Fruehling, MD
<br />21b, IF TRANSPORTATION INJURY
<br />❑ D6ver/Operator
<br />❑ Passenger
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YEs. NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />d home, farm, street, factory, office building, `construction site, ate: (i
<br />CITY/TOWN:
<br />23c. TIME OF DEATH
<br />10:30 AM
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES � NO PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH....
<br />24d. MIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion.ceain 4480188 at
<br />the time, date and place and due to the cause(s) stated. (Signature andTRe)
<br />26a. HAS ORGAN .OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES QV�NO
<br />27. FAME,1`lT)E ANO ADRRESS OF CERTIFIER (Type or Print
<br />Richard Fruettlingr;MD, 3563 Prairieview St Ste 300, Grand Island, Nebraska,' 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />X4.11
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo
<br />June 6,2022
<br />Day, Yr.)
<br />
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