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<br />STATE OF NEBRASKA
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<br />MEN 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 THC NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />OA TE OF ISSUANCE
<br />5/26/2023
<br />LINCOLN, NEBRASKA
<br />202302797`
<br />SAA) 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 />1, DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />JOARna Marla Levels
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dannebrog, Nebraska
<br />F SOCIAL SECURITY NUMBER
<br />506-40.1890
<br />lib. FACILITY -NAME (Pinot Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lsIand 88803'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d STREET AND:; NUMBER
<br />327 Pheasant Drive
<br />10a MARITAL S.V TUS AT TIME OF DEATH Jia Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />11 FATHER S -NAME (First,,
<br />11xis Enevoidsen
<br />Middle, Last,
<br />Suffix)
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />•
<br />,8uHat ❑
<br />® Donation
<br />Q Cremation:❑ Entombment
<br />QRemoval :❑ Other (Specify)
<br />Ea. AGE • Last Birthday
<br />(Yrs.)
<br />86,
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OP OEATN
<br />1,MOSPITALAKI htpatient
<br />• J] ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 06913
<br />3. DATE OF DEATH (Mo;', Dries
<br />May 17,'
<br />6. DATE OF BIRTHtMo. Day, 5ir:?
<br />June 11, 1936
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />❑ Respite Fsc ljty
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />>Ig lNSlDE G(TY LiiMllTs;
<br />D YES I NO
<br />1Ob NAME OF SPOUSE (Pira, Middle, Last, Suffix) If wife, give maiden narfte y
<br />Dale R Lewis
<br />14a. INFORMANT -NAME
<br />Dale R Lewis
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Maymie Chrapkowski
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a, FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town 8.tata):
<br />Abfet Funeral Home 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DEC LNY
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />May 22, 21123
<br />ruu IOne aid examples!
<br />1a. PARt 1. Enter the Chain Of events- .diseases, injuries, or compilcatons-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 E necessary.
<br />IMMEDIATE CAUSE:
<br />NtMEDIATEt:AuSt(Pktld a) end stage Chronic obstructive pulmonary disease, acute on chronic respiratory failure
<br />dWa.6i or eandatonresvkkig
<br />Indeti6lj
<br />Sequentially list conditions, if
<br />any, leedipg to the Ceue9;llated
<br />:en fin#a
<br />Enter the UNDE941ING past,'
<br />(diseeier ur Injurythat Initiated
<br />the events resulting in death)
<br />LAST
<br />CAUSE OF DEATH (See lrftlt
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18
<br />17b Zip node.
<br />{ APPROXIMATE INTERVAL
<br />onset detttt).
<br />>10Ytoears'
<br />PART It OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death blit not resulting In the underlying cause given In PART I
<br />Athetc3aclerO(lO cardiovascular disease, chronic diastolic Congestive Heart Failure, pulmonary hypertension, hypertension
<br />19. WAS MEDIOAL EXAMINER
<br />OR CORONER CONTACTED?
<br />El YE JNO
<br />20. IF FEMALE:
<br />o Not prb5nerlf within pear
<br />❑ :pregdM4h ak grits of death::
<br />❑ 4l0(pregnettr.:but prpgtatOwithin 42 days of death •
<br />0 Net pregnant, but pregnant 43 days hit' year before death
<br />Unknown tt.prepnsm.within the past year
<br />2214.
<br />TE OF INJURY (Mo Day, Yr.)
<br />22d. INJURY ATWORK?
<br />1:1 YES NO
<br />21a. MANNER OF DEATH
<br />Natural. ❑ Homicide
<br />o Accident ❑ Pending Inveatigatfon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator:.
<br />• Passenger
<br />Q Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Jx� PO
<br />21d. WERE AUTOPSY II NDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ No
<br />22c. PLACE OF INJURYAt home, Tann, street, factory, office building, construction site, etif'(S'S
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.(#TCAT)ON:OF INJURY :=;STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 17, 2023
<br />23b. DATE SIGNED (Mo., Day,, Vi
<br />May 22,:.2023
<br />CrrYITOWN
<br />23c. TIME OF DEATH
<br />12:09 AM
<br />18d Tk the beak of my!!knowledge;'death occurred et the time, date and place
<br />andli etothe ceuee(s) stated (Sign aturea nd Tltie)1
<br />Steven Husen, Mr;
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e On the baste of examination and/or investigation, in my opinion death oaCN.
<br />S lima, date and place and due to the mullets) stated. (Signapa@.
<br />.ntO.::
<br />24b. TIME OF DEATH
<br />24d. TIME P
<br />ZIP 400E <:
<br />CED' DEAD
<br />28a. HAS ORGAN OR ',ISSUE DONATION BEEN CONSIDERED?
<br />0 YES El NO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? -
<br />YES NO PROBABLY 0 UNKNOWN
<br />i7. En N6 A ESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE30
<br />4
<br />' l r C.ka•t if/ l fpt-
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ Vas
<br />r..
<br />ON .
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 23, 2023
<br />
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