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<br />STATE OF NEBRASKA
<br />X111111Urlia \F.`._
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<br />ICOPY THISY CARRIES THE RAISED SEAL OF STATE OF IYE RASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE' COI' OF E 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 GP/SSF AN E
<br />12.1 /2021
<br />LINCOLN,': NEBRASKA
<br />T. 1. 1)EDSONTS41AME, (Fret, Middle,
<br />iack Rayrnrand !II cKee
<br />202300242
<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 />t, Suffix)
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Columbus;.: Nebraska
<br />T. S CIAL:SEC3
<br />05-66-7944
<br />ITYNUMBER
<br />16
<br />811
<br />IrACI19TY NAME (if not InstitutIon, give street and number)
<br />Grand la(ar1cl.Regional, medical Csnter
<br />CITY OR TQWrd QF DI°ATH (Include Zip Co
<br />S Gear d ilia ld 388 3
<br />1
<br />19a. RESIDENCE-BTATE
<br />Nebraska
<br />�9d STREETAN,?NUMEEI
<br />' 2Z4
<br />!Ass Road
<br />1 ga 'MARITAL. S
<br />,E.114.
<br />91. F.ATHE
<br />flames McKee
<br />5a. AGE - Lastta)rthday7,5b U
<br />(Yrs.)
<br />ER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE or DEATH
<br />HOSPETALf I Inpatient
<br />0 Eft/Outpatient
<br />DOA
<br />9b. COUNTY
<br />Hall
<br />AT TIME OF DEATH ® Married 0 Never Married
<br />0 Widowed 0 Divorced 0 Unknown
<br />Fit
<br />Middle,
<br />as
<br />Suffix)
<br />$13. EVER:1N U.S ARMED.FORCES? Give dates of service If Yes.
<br />No, No, or Unk.) Yes 06/20/1967-07/07/1967
<br />u 16. METHOD OF DISPOSITION
<br />( !curial3 ❑ 0.1Adion
<br />Cremation ❑ Enteritbment
<br />diartroVai ; Other.(Speclfy)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />19b. NAME OF` SPOUSE (First,
<br />Joan Elizabeth Deck
<br />HOURS
<br />MINS.
<br />3.!DATE OF DEATH:(Mo.;(
<br />November x€7,.202:'
<br />6. DATE OF BIMTH (AMm, Day•
<br />May 29, 4949
<br />OTHER 0 Nurs)ngtlgme/LTG
<br />❑ Decedent's tiome
<br />❑ Other.(SPeclfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Middle, Last, Suffix) If wife, give
<br />IN
<br />12. MOTHER'S -NAME (First, Middle,
<br />Lola Hewitt
<br />14a. INFORMANT -NAME
<br />Joan Elizabeth McKee
<br />Matti
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island'
<br />14b. RELAT1ONSH.i1P TODECEDENT <.
<br />Spouse
<br />16c. DATE (f99-4 Dom, Yr-)
<br />Novembe 24.:212
<br />17a.'FUNERAt 1 0ME NAME AND MA LING ADDRESS (Street, City or Town.:State.)..
<br />AtiraitherOnelVtliome, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATi:i'(See instructions and examples)
<br />18. PART 1. Enter the chain of events - -diseases, injuries, or compiicatlons.hat 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 fines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMISEDIAT6tPlnai a)Cardiacarrest
<br />dla aseoreon4lt(ogresnatf8'
<br />In death}
<br />Sequentially gsi cenritbans, If
<br />any, leading lathe cause rietaa.
<br />en line a
<br />APPROXIMATE INTERVAL.: _.
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />b) Respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EideS'. Aeissiii ;iiNC )M99 c) Pneumonia
<br />(disease err injury Ma t Ratified
<br />B
<br />LAST resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to;Ceafh
<br />Days,,;:;
<br />18 F!ARTIi OTHERSIONIRICANT CONDITIONS -Conditions contributing to the death but notresufUng in the underlying cause given In PART.1
<br />Acute ktdn In u pan to enia seconds to chemotherapy, �Y l ry, cY p ry myelodyspiastio syndrom8
<br />29 IFFEMALE
<br />Not pregnant ttiiinp etyear
<br />Pretp lath of erne 0l deatlt
<br />Na/*4'grlar(t tial pre9ritet wahin 42 days of death
<br />❑
<br />51 ❑ Not pregnant, tut pre(gnaat 43 days to 1 year before death
<br />jys( Unknown ifpl4gnarlt Mthln the jtpet year
<br />2a' )ATE OFda IURY (No> Day, Yr.)
<br />g 22d. INJURY ATWORK?
<br />'S ❑YES NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Heaviside
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. 1F TRANSPORTATION INJURY
<br />Driver/operator
<br />0 Passenger
<br />0 Pedestrian
<br />o Other (Specify)
<br />1S. VMS ftFEtilriAL X i.
<br />OR cORQNEpt OONTAC
<br />© YES 55 NO
<br />21c. WAS AN AUTOPSY P5
<br />❑ YES I 1 NO
<br />21d. WERE AUTOPSY AV1AIt. ABI; E
<br />TO COMPLETE CAUSE OF DEATH?
<br />C7 YES Q NO
<br />22c. PLACE:OF INJUR`I At home, farm, street, factory, office building, constrt
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION INJURY '::STREET & NUMBER, APT.NO.
<br />23a. DATE OF'DEATH (Mo., Day, Yr.)
<br />November 17, 2021
<br />23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Jt mbar 19, 2021 09;30 AM
<br />it tAe jigs! of My knowledge death occurred at the time date and place
<br />ua to the ceases) stated. (Signature and Title)
<br />Scott Heasty, MD
<br />e.
<br />26a. HAS ORO
<br />❑ YES
<br />TQESUSE CONTRIBUTE TO THE DEATH?
<br />YES ;g NO .: PJ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER, (Type or Print
<br />Stott Hes*, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />28a. REGISTRAR'S SIGNATURE
<br />atitiLeiet
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH.-
<br />24d.
<br />EATH
<br />24d. TIME PRONOW4CED
<br />24e. !in the basis of examination antllor Investigation, 111 my opinion deadt adattired ai
<br />•tate time, date and place and due to the causes) stated. (Slgnabae and'Itt%e)
<br />26
<br />AN OR TISSUE DONATION BEEN CONSIDERED?
<br />Ea NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO
<br />YE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Y
<br />November 29, 2021
<br />
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