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<br />ARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />;UMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRD
<br />NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />FFICE; WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />:DATE U!/SSUAIIfCI
<br />3/11/2021
<br />LINCOLN' NEBRAS
<br />1
<br />0
<br />8
<br />Id? .4.40,1kevo
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMANSERVICES
<br />NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 CiECEDENT`:S-NAME (First Middle,
<br />Shir'iey I,.Uella Mance
<br />4 i ITYAND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Last, Suffix)
<br />SOCIAL SECORITY:NUMBER
<br />soft -n-7054
<br />8a. AGE -)"aM Birttlday
<br />(Yrs.)
<br />8b FACU JTY.NAME {if not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c.:CITY OR TOWN OFDEATH /include Zip Code)
<br />Grand island 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9/1,`STREETAND NUMBER
<br />4333 iridiengrass.:Road
<br />9b. COUNTY
<br />Hall
<br />71
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®:Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />1fl MARITAL. STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF Dtr,.4TH`1M90pay Yr.)
<br />FebruarY.43 202.1
<br />6. DATE OF BIRTH (Mo:, DAY,. Yr.)';
<br />September 7}:.1.949 ....
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ OthertSPeNfy)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />. `Hatplce Faallty
<br />9g. )i±ODE CITY:I-1MM
<br />ri YES 140
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donald Ralph Vance
<br />14 FATHERS NAME {First, Middle, Last, Suffix)
<br />Walter Krantz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)::
<br />jJ Surtig 'Irene Bennett
<br />fat;EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Donald Ralph Vance
<br />15. METHOD OF DISPOSITION
<br />Bsrrlar ❑Donation
<br />Cremation DEntombment
<br />❑ Rernovat : ()Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />14b. RELATIONSHIP TQ DECEDLhj1
<br />Spouse
<br />16c. DATE(Mo., Day, Yr) .:,,..
<br />February 16, 2024
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HOMENAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alf Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEA'T'H (See instructions and examples)
<br />18. FART 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 Mutilation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />INIMEDIATECAUSE�taf :. 5)Sepsis Syndrome
<br />:disease orcdndlEbnresulting
<br />in:uesth.
<br />Sequentially list conditions, it
<br />any, leering to the cause listed
<br />o tine a, .
<br />Eit[e. r the UNDERLYING CAUSE
<br />(disease or injury that initiated.
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Abdomen Infection
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Diverticulitis
<br />17b.:Z0
<br />68801';
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />24 Hours
<br />onset to death
<br />2 Weeks
<br />onset to tfeattY<'1
<br />2 Weeks
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />d)
<br />ART II OTHER SIONIFiCANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />onset to death
<br />19. WAS MEDICAL EitAMINER :<
<br />OR CORONER CONTACTED?.
<br />❑ YES ®NO
<br />.t4i•r
<br />Q0�. I•[F FEMALE:
<br />. 1104 pregnant wgnln pastYear
<br />Ptagttagtatarn otdseth.
<br />❑ Not premos, but pmgnent within 42days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown ir.pregnpm wit in the past year
<br />22a; DATE OP;INJ
<br />TOMO., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural [3Homicide
<br />❑ Accident 0 Pending hwestlgation
<br />❑ Suicide ❑ Could not be tl9armined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />❑ Driver/Operator
<br />❑ Ptasenger
<br />© Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES I1NCi
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NQ.,,
<br />22c. PLA OF INJURY -At home,'farm, street, factory, office building, construction site; s ,(Spa jy)
<br />DESCRIBE HOW INJURY OCCURRED
<br />;tOCATiON;OF INJURY STREET '& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 13, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 11 r. 2021
<br />CITWTOWN
<br />23c. TIME OF DEATH
<br />10:13 AM
<br />23d..1`o the best '4 4". knowledge;; death occurred at the tlme, date and place
<br />al 9 due to the causes) fid. (Signature and Title)
<br />Rvan D Crouch, DO
<br />26, O D?OBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES .tint NO ❑PROBABLY ❑ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />`7Jiti'�.ODiir
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD •
<br />24a. tan the Rials of examination and/or inveatlgatlon, in my opinion th accurrad at
<br />thatitae, date and place and due to the causal.) stated. (signet urn anti Ttse)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />-YES] NO
<br />27. NAME TITLE AND ADDRESS OF CERTIFIER` (Type or Print
<br />)cyan D rough, b0, 800
<br />N Alpha St, Grand Island, Nebras
<br />, 68803
<br />26b. WAS CONSENT GRANTED?.
<br />Not Applicable If Zea Is NO ❑YES:;
<br />28b. DATE FILED WRREGISTRAR (Mo., Day, Yr.)
<br />March 11, 2021
<br />00
<br />
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