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<br />WHEN' THIS > COPfr, CARRIES THE ;RAISED ;;SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE . >A TRUE COPY .,OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA ` DEPARTMENT OF HEALTH AND HUMAN • SERVICES, ' VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />..... ............... .............. .
<br />DATE OFiSSUANCE
<br />11/3012018
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<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,
<br />Edie Janet Prouty
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Last, Suffix)
<br />5a. AGE: LassBirtbday
<br />tYrs.►
<br />71
<br />i
<br />7. SOCIAL SECURIT
<br />44.1-44-8557
<br />NUMBER
<br />Sb FACILITY -NAME (ItnDt i)lsdwtion, give street and number)
<br />Bryan Medical Center West
<br />$c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68502
<br />9a. RESIOENCE,STATE
<br />Nebraska
<br />9d. STREET AND NUMBER`
<br />304 W. 16th Street
<br />IRr. UNDER;I YEAR
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL I.i inpatient
<br />❑ ERiOutpatlent
<br />bbA
<br />9b. COUNTY
<br />Hall
<br />18a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Q Manned, but separated 0 W)dOwed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Earl Norman Hunt
<br />13. EVER IN U & ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />is. METHOD OP CISPOSfi1ON
<br />❑ curial 0 Donation
<br />Cremation 0 Entombment
<br />O Retytoval `© ONfer(Specify)
<br />tOb,<;NAME
<br />Ronald .. prouty::: Sr.... .
<br />Sc. CITY OR TOWN
<br />Grand: island
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.'
<br />!t, tt+tNllHr r� - 11urrNr
<br />111111/ll/r
<br />;p`''' wee.a icu lilnry e•lev ser;
<br />g�rnr1, f ii
<br />.�l h)i1 rlllpl„)1 .�
<br />1499
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 20, 2018
<br />OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />Decedents Berne
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />sg. *aim CITviiiisT>
<br />O. Yes ❑ NO
<br />F SPOUSE (First, :: , Middle, Last, Suffix) if wife, give maiden name
<br />•
<br />14a. INFORMANT -NAME
<br />Ronald Prouty Sr .
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Midese,
<br />Velma Murrin
<br />olden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />1So. Was (ma., f;yay, Yr:)
<br />November 22, 2018
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />is
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S, Locust Street. Grand Island, Nebraska
<br />CAUSE OF DEATH 1 e instrue
<br />CITY I TOWN
<br />Gibbon
<br />ns and examples))
<br />1E. PART I. Enter tire.: chain of MA/ins. -diseases, Mjurles, or complicsaons-n+at directly caYSad tl» dsath. DO FtOT erdsrlsrmnaliavenue such negotiate arrest,
<br />xospiraMry arrest or gano%s, alar nbANanen without showing the etiology. DO NOT ABSREvfifTE. saa only one cause(en a firmAdd additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDItTE CAUSE (Final a) Acute Hypoxic Respiratory Failure
<br />dlesaaeor:ondltionresulting k ::
<br />•
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />seremuanyttet cobdiaene, s b) Diastolic Heart Failure
<br />any eating to the Gauss (iattw•
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />tdleeaator tnituy:that inigated
<br />fi a eventeresuittng 3n death)
<br />LAST.
<br />DUE;TO, OR ASIA CONSEQUENCE OF:
<br />c) Morbid Obesity
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1Tla ZADCOG*
<br />68801
<br />APPregpm., •INT I
<br />onset to rah
<br />Weeks
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />COPD, Acute Kidney injury
<br />20. IF FEMALE:
<br />® Not pregnem within past year
<br />0 Pregnant at time of death
<br />:Nat pregnaftrbut Pnugndllt whim 42 days of th
<br />© Not pregnant but pregnant 43 days to 1,year before death
<br />Unknown If poignant Within t e past year
<br />21a. MANNER OF DEATH
<br />® Natural, 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />Suicide ❑ Coatd not be dalemtined
<br />21* 1PTRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 May specify)
<br />•
<br />19. WAS MEDICAL EXAMINER
<br />0)R C0*0.14ER CONTACTED?
<br />❑ YES is Na ..::.
<br />21c. WAS AN AUTOPSY PERFORIN
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY F1NDINOS AVAN.ABL@
<br />TO COMPLETE CAUSEOF:DEAr .
<br />❑YES
<br />22a. DATE OF INJURY (Mo.,: Day, Yr.)
<br />22dif1JURYATiWO
<br />RkC? ..:;
<br />.EIYES ❑NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory,
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET &
<br />R, APT.NO.
<br />r const
<br />CITYITOWN
<br />STATE
<br />nets tic fi6;1TN (Ma, Day. Yr.)
<br />November 20..2018
<br />3b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 20. 2018 08:57 AM
<br />9d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />radette Variiek. MD
<br />24a. <[IA 18IGNED (Mo., D
<br />Yr.)
<br />b.
<br />24c.;PRONOUNCED DEAD (itlla, Day, Yr.$ 24d. TM
<br />24e. On the basis of examination and/or investigation, in ail animist death neared at
<br />the time, date and place and due to the cause(s) stated. an)I Title)
<br />28. DID TOBACCd U E CONTRIBUTE TO THE DEATH?
<br />M) YES ❑ NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Bradette Varilekt. MD, 2300 S 16th St, 7th Floor Lincoln, Nebraska,,68502
<br />28a.:REGISTR uI R S113NA1::URE
<br />28a. HAS ORGAN OR`TISSUE DONATION BEEN CONSIDERED?
<br />®YES ■ NO
<br />28b. WAS CONSENT GRANTEOI
<br />Not Applicable If 280 is NO ` ❑ YEs
<br />28b. DATE FILED BY REGISTRAI
<br />November 28, 2018
<br />
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