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<br /><_________STATE OF NEBRASKA
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<br />;WHEN THIS CORY CARt'IiIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF TF/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 Oi!SSUANCE
<br />2/2412€)22
<br />LINCOLN, NEBRASKA
<br />ormwor
<br />1 oa.OsOENT84I'IAME (First, Middle, Last, Suffix)
<br />11 Robert Dears Petrick
<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 />ITY AND STATE ORTERRITORY,
<br />2. SEX
<br />Male
<br />R FOREIGN COUNTRY OF BIRTH
<br />roken Bow, Nebraska
<br />106-70-490,3
<br />Sts. FACILITY-NAME.(ifno;institu
<br />2204 N. SVcamore'Stree
<br />HOURS
<br />8a. PLACE OF DEATH
<br />HOSPITAL [] inpatient
<br />0 ER/Ou patient
<br />3. DATE OF DEATH fMO.,, pay Yr }
<br />February 14, 2022. .
<br />S. DATE OF BIRTH IMO., Day, Yr)
<br />July 9,1949 _.
<br />OTHER 0 Nursing Home/LTC HospMce FaQjlity
<br />I1 Decedent's Home
<br />8c' CITY OR TOWN OF OATH (Include Zip Code)
<br />Grand Island 58801
<br />1ESIDENCE-STATE
<br />ebraska
<br />• rte, 9d a3TREET AN D NUMBER
<br />is 2204 N. Sycamore Street
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />los. MARITAL .STATIJS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, hutesparated ❑ Widowed 0 Divorced 0 Unknown
<br />91 "FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Bernard Petrick
<br />13. EVER IN U.8 ARMED'FORCES? i Give dates of service if Yes.
<br />{Yes, No, or Link) ES 07/2811969-08/26/1969
<br />�16 I4IETHOD OF D1SPtiSITION
<br />9f. ZIP CODE
<br />68801
<br />ii INS€DE CI'rYU.MIT3
<br />E E Oso
<br />fOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Judy Petrick
<br />i3urial Donation
<br />Cremation ❑ Entombment
<br />❑'Removal ❑ Other (Speciy)
<br />18a. EMBALMERSIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S=NAME (First, Middle, Malden S
<br />Dorothy Lewis
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Govier Brothers Crematory
<br />17,si FUNERALr ROME NAME AND MAILING ADDRESS (Street, City or Town Stats)
<br />GovleBrD#her$. Mty:rtuary )rid•, 542 South 9th; PO Box 665. Broken Bow, Nebraska
<br />14b. RELATION$51 TO DECEDENT
<br />Spouse
<br />18c, DATE (Mo , Day, i't )
<br />February.96, 2022
<br />CITY / TOWN
<br />Broken Bow
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See itstruttions 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 cause on a line. Add additional lines If necessary.
<br />INMiIEDlATE CAUSE (FtrralI
<br />disease or ir10 . Yaaibddg:
<br />in tleatbl
<br />Sequentially list conditions, If..
<br />any,leadIng to the cause died
<br />od:lIne e
<br />IMMEDIATE CAUSE: i- onset foes
<br />al respiratory failure 3'Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)metastatic pancreatic cancer
<br />DUE TO OR AS ACONSEQUENCE OF:
<br />EraarthituNDEnLvtisecauise C)
<br />(disease or inJury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1a ;PART I), OTHER SIGNIFICANT CON
<br />pulmonary embolism
<br />onset to death.
<br />16 Months
<br />DITIONS-Condltions contributing to the:death but no resuiting'iit the underlying cause given in PART I.
<br />99. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />;D IF,FEMALE•;:;
<br />❑ ;Not pi egnaa within
<br />Pregnadt a atria p??
<br />atpregose t, hutpregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />ynknown If:pregnantwithin the past year
<br />2a;:iJATE OF (kiJURYtMo, Day, yr,)'
<br />d. INJURY AT WORN
<br />.: ❑ YES .;:.:❑ NO
<br />OCATPONOF INJURY:STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />Natural ❑ HomiClde
<br />❑ Accident tiPenOg InVestlgeiion
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />Driver/Operator
<br />'.❑ Passenger.
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />INJURY) 21c. WAS AN AUTOPSY PERFORMED?
<br />❑vas: ANO
<br />21d. WERE AUTOPSY 011+1DINos AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />22c. PLACE OF INJURY -At home, farm, Street, factory, office building, construction site, alt
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 14, 2022
<br />CITYITOWN
<br />23b. DATE S.LGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 16, 2022 09:26 AM
<br />23d: To the f}est ot:my knowledge, death.occurred at the time, date and place
<br />ami due to the i euse(s) elated (Signatureand Tide)
<br />Isaac J. 'Berg; MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />C] YES
<br />Ail Nog'❑ PROBABLY 0 UNKNOWN
<br />NAME. TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Bei', MD, 729 North Custer Avenue,; PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />zap 8iz�nk.
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />P
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD.:...
<br />24e. On the basis of examination and/or investigation, In my opinion death eeouneeet ..,
<br />the time, date and place and due to the satirists) stated, (signature aad Titttle)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES al NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0YES' 0 NO.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 21, 2022
<br />
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