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<br />( STATE OF NEBRASKA _ >tttD • „„' " "
<br />1#4 4415WinWl.:"' g"..5"4 ?IV 'itskii1‘,1,(060)•)11114104)N Wtt
<br />WHEN THIS COPY CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CER77FIES THE DOCUMENT BELOW TO
<br />SEA TRUE COPY OF 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 OFISSUANC
<br />4/11/2023 4tJl15444-44.
<br />LINCOLN, NEBRASNA - 202 0,1 9 4 4 SARAH BOHNtIsTKANIP7, .
<br />_ ASSISTANT STATE REGISTRAR
<br />D EAPNADR;I AN 'II )1RIVEIIII
<br />• STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />344444•.J1. capaceRremArog •,(fp..at, Middle, Last, Suffix)
<br />Dennis Wayne Benson
<br />4. CITYAkb SLATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7.s9.ciimoop14Ri1eNuMBER
<br />$054.0427.:12
<br />Sb. PACILITYNAME:(lthrit Institution, give street and number)
<br />43
<br />E- • 1008 East 5th
<br />t
<br />0
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />••••:: • •••
<br />rand island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, SVI5T4.15DNUMBER1008 East 5th
<br />, •
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />ft...UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />ea,pLaca OP DEATH::::.
<br />HOSPITAL'Er Inpatient
<br />o ER/Ou patient
<br />000A
<br />9b. COUNTY
<br />Halt
<br />10e.:.554.1ITAI4TATUB.AT TIME OF DEATH ig] Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />,M7THER'Sf4PAE4F!#M, . Middle; Last, Suffix) -
<br />llaleUW-Sentbri-];',..:!, -_ •
<br />11 EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DERTNimo.,94$4-yr.,)
<br />March 2, 201r, ,•••••A
<br />6. DATE OP BIRTRAMo.,I2*E4*-)
<br />May 30,
<br />. . • • ''
<br />... OTHER 0:Nutting •EHospice PA:08140.,1%
<br />IJ Decedent's Home
<br />• . 0 Other (SpecIfy).]:„.',::::.:::,-•••::•: • •
<br />18d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />$. 1NSIDEC11YUMVTS
<br />YES
<br />13:141;y:
<br />10b. NAME °ESPOUSE (First, Middle, Last, Suffix) If wife, give malOen nests
<br />Sandra K Kelly
<br />14a. INFORMANTASME
<br />Sandra K BensonWife
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname
<br />. .
<br />Helen M Davis- _ , _
<br />14b. RELATIONSHIE'rotiaCEDENT:':.
<br />":•&"
<br />••o
<br />0
<br />•••••
<br />0.
<br />15. METHOD OF DISPOSITION
<br />cqi:r44:00:ElOntonibment
<br />0: Removal0�thdrspecify)
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a..E.umERAL...ktomEr*M.E AND MAILING ADDRESS (Street, City or Town, Stats)
<br />Apfel Funeral Home 123i,A4,..2nd, Grand Island, Nebraskk:.',
<br />16b. LICENSE NO.
<br />1191
<br />CITY/TOWN
<br />Grand Island
<br />18c. DATE Day,
<br />March
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1$. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respitatory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline. Add additional lines If necessary.
<br />immeNATE CAUSE (Flaw! a) Lung Cancer With Metastatic Disease
<br />*mums or condition resulting
<br />In ht :
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ilitilt conditions, b)
<br />Sequentia
<br />leading to the cause listed....
<br />...on line . .
<br />•••••• DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE
<br />(diseisePOrItduCytnat Undated_
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST.d)
<br />APPROXIMATE INTERVAL
<br />9 Months
<br />10•1!.ARrikoTmE6r4IONIFICANT CONDITIONS -Conditions contributing to the death but nOretiORIng10;*&i.inderlying cause given In PART I.
<br />PCIIMORSIO(fIROD1150141VT Of Right Upper Extremity, COPD, DepreSSIOn/AnXieti;:flypielipldMISS,FibroMyalgia; Hypertens on
<br />P/at pregnant Within panfyesr
<br />aNtti.fiegnitrit,,butpMgnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />D Onknown'itpregnant within the past year,
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />o Accident 0 Pending Inveitigatton
<br />0 suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator "
<br />'0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onsetS death >:
<br />onset to death
<br />19. WASMEDIQALE$AMNaR.1:
<br />fokdoRcteleik0OpreAcia6r,
<br />YES OD NO
<br />21c. WASAN AUTOPSY PERFORMED?
<br />DYES 1NO
<br />21d. WERE AUTOPS4EISibINGSAVARAIILE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0
<br />'.16
<br />43
<br />4
<br />22t.::::pATE::or:INJu!ty::::.(m.;::Day, Yr.) .:.:
<br />•
<br />22b. TIME OF INJURY
<br />22c. PLACE DE INJURY -At home, farm, street, factory, office building, construction slte,MES.OMarifii
<br />22d. INJURY AT WORK?
<br />DYES
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OF INJURY sTREETs wumeEk, APT.NO.
<br />CITY/TOWN
<br />STATE *:
<br />E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 2, 2011
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 22, 2011
<br />23c. TIME OF DEATH
<br />08:00 PM
<br />4 TOP* beet of fny knovAedge, death occurred at the time, data and place
<br />and 5u4 to MS saUMOO stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e.t3ittheiMils of examination and/or Investigation, In my opinion deininedifirePe
<br />the lime date and place and due to theMiute(s) statecL(gignatureiniglitte)'
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />ei
<br />Not AppliCable If 26a is NO DYES u NO
<br />27:14AmerrLBANc:AcoftEss OF CERTIFIER (Type or Print
<br />KitriberliA rvittkels, MD, 729 North Custer Avenue, Grand island, Nebraska, 68803 • -
<br />28a. REGISTRAR'S SIGNATURE A
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 22, 2011
<br />
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