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<br />STATE OF NEBRASKA
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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 OP THE 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 OF'ISSUANG
<br />1 /3/2023
<br />LINCOLN, NEBPLAS
<br />202301729''
<br />SARAH BOHNENKAMPT j
<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( DECI:171+NT -NAME (First, Middle, Last, Suffix)
<br />Donald bean Metcalf .
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sargent, Nebra
<br />wog. sew/777N
<br />807-86.0539
<br />ER
<br />5aAGE • Last€BTrthday
<br />(Yre.)
<br />77
<br />E
<br />1
<br />1
<br />1
<br />3
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />Tiffany Square Care Center
<br />Sc CIT1r OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 613803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. S1 REETAND NUMBER::
<br />31 I9 West PaidieV Avenue
<br />9b. COUNTY,
<br />Hall
<br />10a.MARITAL STATUS AT:TIME OFDEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1i. FATHER S NAME (First, Middle, Last, Suffix)
<br />Carl L • Metcalf
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unk.) Yes % 10/05/1965-10/04/1971
<br />16. METHOD O.F..
<br />O BuHal
<br />J Grematioi1
<br />❑''Removal
<br />DI
<br />POSITION
<br />Donation
<br />Entombment
<br />ler (Specify)
<br />8b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ] ] Inpatient
<br />❑ ERJOu patient
<br />0 DOA
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Janice Carlson
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Ma, Day•Yr);;::
<br />December 17, 2022
<br />6. DATE OF BIRTH (Mo., Day, Yr.)`
<br />OTHER 511 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />90. APT. NO.
<br />9f. ZIP CODE'
<br />68803.
<br />14a. INFORMANT -NAME
<br />Janice M Metcalf
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S.NAME (First, Middle,
<br />Rozelta Huss
<br />1Bb. LICENSE NO.
<br />16d. CEMETERY., CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATI{(See instructions and examples)
<br />fi (NS)D0 CITYLiMITIT
<br />e, give maiden name
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DEC.Ei1ENT•
<br />Spouse
<br />16c. DATE (Mo., Day,,,Yr.)
<br />December 24, 2022
<br />1S. 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 ventrlcularnbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional sines If necessary.
<br />IMMEDIATE CAUSE:
<br />iv/APIA/5 Clause (Finer a) Non -small cell lung cancer
<br />meanie or 40ndlli0M1ro*alaHg
<br />In death# !„
<br />Sequentially Oat condltior
<br />any.,IeamaB to 0.ra'c000
<br />'STATE
<br />Nebra
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />Enfar the UNDERLYING CAUSE
<br />(disease ar Injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART 11 O'tRS!GNIFICANT CONDITIONS -Conditions contributing to the death b
<br />Not pre9mnt;wititin Pa
<br />❑ Pregnant attime ofdaath
<br />❑ #Yet pregnant but pnigrxnt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before Wath
<br />❑:; Unknown it psagnantwi hr the past year
<br />22a. DATE OF 1FFTURY iMlsw Day, Yr.)
<br />22d. INJURY AT WORK?
<br />[YES ONO
<br />22f, LOCI
<br />8'
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December:21.2022
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />not real
<br />the underlying cause given In PART 1.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑>Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MED(QAL;EXAMtNER
<br />OR CORONER:CONTACTED7
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORM'
<br />0 YES Oil NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACEOF INJURY -At home,`farm, Street, factory, office building, construction site, elt :(Specify)!'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ION'OF INJURY:: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 17, 2022
<br />cITYJTOWN;'
<br />23c. TIME OF DEATH
<br />05:10 PM
<br />23d. To the beat of my knowledge, death occurred at the time, date andplace
<br />and due td the causa(s) stated. (Signature and Title)
<br />Richard Fruehlinq. MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 9 NO `.,I PROBABLY 0 UNKNOWN
<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 />24a. On the bail. of examination and/or investigation, M my opinlon Watn Q40umd a!
<br />I
<br />time, date and place and due to tiro causes) stated. (Slgnatu a snit ilpe)
<br />26a. HAS ORGAN ORTissug DONATION BEEN CONSIDERED?
<br />YES E7
<br />27. NAME TITLE ANDADDRESS OF CERTIFIER (Type or Print
<br />Richard Frueh(ing,':MD, 3563 Prairieview St Ste 300, Grand Island, • - <a, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Appficabie If 28a M NO ]YES . ❑ NO::
<br />28a. REGISTRAR'S SIGNATUREjG>+t4F
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 28, 2022
<br />
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