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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 />BEA 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 OP ISSUANC
<br />....... ..........................
<br />....... .............................
<br />1/20/2023
<br />LINCOLN, NEBRAS
<br />1
<br />302714
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGIST
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DSCEDENT'SoNAME (F) .st, Middle, Last, Suffix)
<br />Jacptlelina S Hetrick
<br />4. CITY ANb STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand, Island, Nebraa
<br />.80CIA(4E0URI1 . UMEER
<br />8Ct5-76 7535
<br />844. AGE Last Birthday
<br />(Yrs )
<br />65 •
<br />8b. FACILITY•NAME (If not l
<br />n, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />Ec.:WY OR TOWN OF DE4VIH (Include Zip Code)
<br />Grand Islami 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska.
<br />9d sSREtETANDNUMHart
<br />1935.FreectonvOriVe
<br />I.
<br />9b. COUNTY
<br />Hall
<br />ib. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />HOSE PITAL O Inpatient
<br />0 ER/Ou patient
<br />❑ DOA
<br />M
<br />10a. METAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated: ` i Widowed 0 Divorced'. 0 Unknown
<br />11. FATHER'S -NAME (FI
<br />Weston H: Bloon
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 00392
<br />3. DATE OF DEATH _(MO., 41y YTS;;:
<br />():1023
<br />Januarvl, ..........'
<br />.IM
<br />6. DATE OF BIRT o., Day, Yr:)
<br />August 21,:
<br />OTHER ® Nursing Home/LTC'
<br />Decedent's Home
<br />❑ Other (Specify)
<br />COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9r. ZIP CODE
<br />68803
<br />WWb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden;/
<br />Lynn M Hetrick
<br />12. MOTHER'S.NAME (First, Middle, Maiden
<br />MON St
<br />MaE Murphy
<br />4IN 3E GITY UMITIi
<br />13. EVER IN U S ARMED FORCES? Give dates of service H Yes.
<br />8 (Yes, No, or Unk.) No
<br />u .18. METNOD OF DISPOSITION
<br />❑ Eurtal ❑ oona
<br />tjtson
<br />Cretnatio❑n Entombmnt
<br />e
<br />Removal s ❑Other (Specify)
<br />f.:17a. F:UNERA
<br />HQME NAPA
<br />14a. INFORMANT -NAME
<br />Caleb Hetrick
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />AND MAILING ADDRESS (Street, City or Town, State)
<br />1
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />•
<br />1412 RELA DN$HIP SO ANT'''
<br />Son I
<br />16c. DATE iM°l,..l
<br />January M.
<br />''ATE :
<br />Nebraska
<br />I*Ix MP:Code::
<br />CAUSE OF DEATH (See inistruotions and examples)
<br />18. PART 1. Enter the chain of events' .dplsdaes, injuries, or compilcations4hat 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 N namesIMMEDIATE CAUSE:
<br />a)Mettt
<br />as a s lung cancer
<br />1MMED1ATE.CAUSE(Fial i
<br />diseaus eandieriln Bunting
<br />in demi DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Ila conditions, is b)
<br />::any, (##dins to tla pause ilsnd
<br />Mn IM a.
<br />Enter th.:ONDERI.YIN01... $E:
<br />(diseue dr InJury nkat inlllated ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />18. MART1I. OTH
<br />r Y. IF;FEMALE;
<br />E wetp ntwahln$stf
<br />.St [ Pregneld at$gte of deem
<br />.1:: 0 Naptagaai; but praglutnt within 42 days of death
<br />4r 0 Not pregant, but pregnant42 days to 1 year before death
<br />::: :::❑ .Unknown 5PMt
<br />fAern vdtdaren Pat year
<br />FICA
<br />CONDITIONS.Conditons contributing to the death but not resulting in the underlying cause given in PART I.
<br />22d. INJURY AT W
<br />©.YES ❑.No.
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pantiles Inveatlpatlon
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />210: IF TRANSPORTATION INJURY
<br />0 0/h/e Operator
<br />01ifeetlenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAS M DICAL EXA$Iil
<br />OR CORONER,LONTACT
<br />❑ YES '` 511 NO
<br />21c. WAS AN AUTOPSY t,,uyt;s1y,PPN4N,Meert,
<br />El Yeti 1410
<br />21d. WERE AUTOPSY iiiNtfiNGSAViiiAki
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NQ
<br />22c. PLACE.OF INJURY.At Noma, farm street, factory, office building, construction
<br />ESCRIBE HOW INJURY` OCCURRED
<br />22f :4 )ION
<br />CATION„ INA RY:'. STREET&NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Jan
<br />January 10, 2023
<br />23b. DATE
<br />uary 1SIGNE2D 2023 (Mo., Day, Yr.)
<br />8 G 2dd Torbo bot of My; laowledge, death occurred at the time, date and place
<br />Bend true tOthe eause(s) stated. (Signature and Title)
<br />1 -Steven Husen, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />05:55 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />E 1,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.).
<br />24d. TIME P DEAD .
<br />24e. On the basis of examinaton and/or Investigation, In my opinion ds$h ocoured.48
<br />the time, date and place and due to the cause(s) stated. (S 'Intal
<br />24 Dip TOBACCO USE CONTRIBUT I26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES 0 NO PrtOBA I)I ❑ YES • IX) NO
<br />27. 4NAME. TITLE:AND ADDRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD 2116 W Faidley #400, Box 9802, Grand island, Nebraska, 68803
<br />ad 0
<br />E TO THE DEATH?
<br />l3LY 0 UNKNOWN
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS cameNT
<br />Not Applicable If 26a Is l
<br />I0
<br />28b. DATE FILED BY RECOSTRAR (Mo., Day, Yr.)
<br />January 17, 2023
<br />
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