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<br />STATE OF NEBRASKA
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<br />WHEN MS 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 DEPO$ffORY FOR VITAL RECORDS
<br />DATE or ISSUANCE
<br />1213/2021
<br />LINCOLN, NEBRASKA
<br />202302793
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />1`Iv
<br />i1.
<br />:to
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECERENT $NAME (F(rst, Middle, Last, Suffix)
<br />tllery Jana Ffant 3s Lee';
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Davenport; Iowa
<br />9. 3.CIAL:SECt.IRIT7NUMBER
<br />480-4Z3387
<br />3387
<br />Bb. FACIIJTY-NAME U)f not Institution, give street and number)
<br />508 White Avenue
<br />CITY.OR TOWN OP DEATH (Intl ustei Zip Code)
<br />Grand Island 68803
<br />9a RESIDENCE STATE
<br />Nebraska''
<br />8d. S..TREFTANDNUME£FR:
<br />508 Witiite Avenue:
<br />Sc. AGE Last Birthday
<br />(Yrs.)
<br />89 '.
<br />5ti UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />:;:HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />Ob. COUNTY
<br />Hall
<br />10a MARITAL STATUS ATTIRE OF DEATH ❑ Married ❑ Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S,NAME (First,
<br />Walter Hermes
<br />13 EVERT
<br />• (Yes, N:
<br />Middle, Last,
<br />Suffix)
<br />ARMED FORCES? Give dates of service. if Yes.
<br />ink.) No
<br />15. METHOD OF DISPOSITION
<br />Ejen,fal ❑Ilatratt�tt
<br />❑ Orsmattilili;. ❑ Entomtonent
<br />❑ rletnotrai:,.❑Qbter'(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2._ SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />3. DATE OFINAT/141004iptty, Y4
<br />November 11:, 202t
<br />8. DATE OF BIRTffl(Mo , bay44)
<br />MINS.
<br />April 23, 1
<br />OTHER 0 Nursing HomeILTC
<br />I Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />Pe. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />TNI
<br />1(/U NAME OF SPOUSE (Ron, Middle, Last, Suffix) If wife, give maiden mane:::'
<br />Robert E Lee
<br />14a. INFORMANT -NAME
<br />Mary Lee
<br />18a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL$OME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curr rr Funeral C6rapeI, 3005 S. Locust St., Grand Island, Nebraska
<br />12.MOTlfERS-NAME (First, _' Middle,
<br />Mabel Tobin
<br />16b. LICENSE NO.
<br />1092
<br />CITY / TOWN
<br />Grand Island
<br />III
<br />14b. RELATIONS
<br />()SUW er
<br />16c. DA (�, Day, Yr) ;
<br />November 19, 2021.;
<br />ee otione and examples)
<br />18. PARTI, Enterth'e 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 />IMMEDIATE CAUSE:
<br />iMNIEtNA'rEtKAii$ tPbtal :! a)COVID-19 infection
<br />disease:'of:� Sndit
<br />Sa4ufetialty list conations, if
<br />any, leading to IhS cause listed
<br />Enter the UNDERLYING CAt/SE.
<br />(di ash br Inju4i that in tact
<br />the events res
<br />LAST,
<br />In. death):
<br />CAUSE OF DEATH (S
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Type2 diabetes, morbid obesity
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />instru
<br />APPROXIMATE INTER*AL"
<br />)
<br />to death
<br />18.PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART L
<br />ethernet( de#tlenpa (18 to 7C on Hospice admission). Patient with Advance DireCt)ve directing no hospitalization, comfort cares
<br />only
<br />20. IFFEMALE:
<br />Not pggnatlt 44ihin PSStyear
<br />Preat a itS Of aatit ;.
<br />CI;;
<br />Nat pregnant:; but piegnarit wlthM 42 tlays or death
<br />❑",
<br />❑ Ne pregnant, but Pregnant 43 Jaye to 1 year before death
<br />1,. ❑ Unknown It pregnant within the past y r
<br />22e DATE OF INJURY (Mos; Day, Yr.)
<br />22d.INJURY AtWORK?
<br />❑ YES ❑ NO
<br />22e. D
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 pending investigation
<br />❑ Suicide, 0 Cauld not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />DPassenger
<br />❑ Pedestrian
<br />❑ Other(Specify)
<br />19. WAS .OALEXAM.NER..
<br />OR crootieiki0ONfaio.F00
<br />aNc
<br />21c. WAS AN A PE
<br />D YES 6s1 Nli
<br />21d. weft AUTOPSY Pti AvAtUtt
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ _YES ❑ NO ..
<br />22c. PLACE OF INJURY.At home, farm, street, factory, office building, constructIon
<br />CRIBE HOW INJURY OCCURRED
<br />pt.rc..smns7:;Is4kstyt. STREET:& NUMBER; APT.NO.
<br />23a. DATE tDP'DEATH (Mo., Day, Yr.)
<br />November 11, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo Day; Yr.) 23c. TIME OF DEATH
<br />Noventer262021 Unknown
<br />Teethe beet of myknowledge, death occurred at the time, date and place
<br />end due to the cadse(s) stated. (Signature and Title)
<br />Michelle D Schiei, APRN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD(Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PR+
<br />t. on the basis ofexamination antl/or Imrestigation, le sty eptiiiaa.d!esQih
<br />the tinier date and place and due to the cause(e) states. (sig slid 1)tla)
<br />D
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES • INO 0 PROBABLY 0 UNKNOWN
<br />27NAME, T(1L.E AND ADt)RESS OF CERTIFIER (Type or Print
<br />Michelle DI Soho! APRN 1201 Allen Dr Ste 163, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ( NO
<br />28a.
<br />STRAW'S SIGNATURE
<br />L
<br />28b. WAS CONSENT (
<br />Not Appltcable'if 28a is
<br />28b. DATE FILED BY RE R
<br />November 30, 2021
<br />
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