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<br />STATE OF NEBRASKA
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<br />WHEN THIS COP? CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 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 />BATE OP ISSUANCE
<br />1013/2023
<br />LINCOLN, NEBRASKA
<br />202306028
<br />jew
<br />SARAH 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, DRCFpENT5-NAME;(First; .: Middle, Last,.
<br />Marlene';:: RuthAndersen
<br />Suffix)
<br />4. TYAND:a7ATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Holt, County, Nebraska.
<br />.4.06IAI: SEetIte Y NuiNBER
<br />507 80 3:137
<br />6a. AGE - LastStrthday'
<br />(Yrs.)
<br />84:. .....
<br />8br'<FACILITY<NAME et not Institution, give street and number)
<br />.:CHI HealthSt.: Francis'
<br />8c: CITY OR TOWN OF DEATH'(Include Zip Code)
<br />rand Island $603
<br />as. RESIDENCE$TA'
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sb, UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PILACE OF:DEATH ;
<br />HOSPITAL ❑'inpatient
<br />ER/Outpatient
<br />0 DOA
<br />9d STREET ARD NUMBER
<br />4(17 Lake:Streej
<br />leai MARITAL STATUS ATTIME OF DEATH ® Married 0 Never Married
<br />Er Married, but separated `:❑ Widowed. 0 Divorced 0 Unknown
<br />11:.EATHER $.NAME (F..Irst,• Middle,. Last, Suffix)
<br />Ralp#1 'ThurlDvV
<br />13. EVER IN 1.1.5 ARMED'FORCES?' Give dates of service if Yes.
<br />• (YesNo,:or Unk.) No
<br />`16. METHOD OF DISPOSITION ; .
<br />Burial ❑Don tion . •
<br />l Crematlan 0 Entombment
<br />•
<br />Removal:' ❑ Odter, (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home .
<br />❑ Other (Specify).
<br />3. DATE OF DEATH::(NFO , Ds)1r Yr)
<br />September 14, 2023
<br />6. DATE OF BIRTH(IVIo.,
<br />February.27, 1939 , :...
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ye. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Fatilf 14(
<br />lab. NAME OF SPOUSE(First, Middle, Last, Suffix) If wife, give maid
<br />Jerald W Andersen
<br />14a. INFORMANT.NAME
<br />Jerald W Andersen
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />•9g e)elegCITY UMITS'
<br />j. YES ❑NO
<br />12 MOTHER$ -NAME (First, Middle, Maiden Surname)'
<br />Seat Jean Oxner
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />h a FUNERAL;HOME NAME 'MAILING ADDRESS (Street, City or Town,.state)
<br />Apfel funeral) one; 1123 W..2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1537•
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />t8: PART I. Enter Ste chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, •
<br />respiratory hires t, 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 />Ia1meptATE CAUSE (Pinel
<br />disease or aandition resulting;,
<br />athl
<br />Sequentially.gstbondltione, it
<br />tending:to the cause listed
<br />online a
<br />Enter the UNDERLYING -CAUSE'
<br />idisease or )iyiirjyttult Ifni hied -.
<br />the events reskiftltg in death)
<br />UtsT
<br />a) respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) covid 19
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />... .. ... .._..... d)
<br />1taN.ettial OTHER SIGNIt ICANTCONDITIONS-Conditions contributing to the death
<br />braByCErdrB hypSrte... •'
<br />2tl•.yiF
<br />pragdant wnhM Pa*ryear
<br />rgnt at time of death
<br />pregltaiai but fS9nenty ithIn 42 days of death
<br />Not pregnant but.pregnant 4S.deys 1Q t,year before death
<br />0 VIlliltmliattiPregnerit within tiro pest year
<br />a DATE.P INJUI
<br />(141c Day,Yr.)- • .
<br />22d. INJURY A r WORK?
<br />:DYES, -ONO;
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />tit not re
<br />22b. TIME OF INJURY
<br />22c.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CE." OF INJURYAt
<br />TION OF INJURY . STREET.&'NUMBER, APT.NO. CITY/TOWN'
<br />23a DATE 'OFi3EATH:(No., Day, Yr.)
<br />SePtember 14, 2023
<br />23b. DATE>SIGNED (Mo., Day, Yr.)
<br />Septehiber.21,• 2023
<br />23c. TIME OF DEATH
<br />10:00 PM IA
<br />'3d Tti tha beat of:my: knowledge, death occurred at the time; date and place
<br />and due to the tause(s).elated: (Signature and nue)
<br />Antho•ny F. Cook; MD
<br />25. cm TOBACCO USECONTRIBUTE TO THE DEATH? •
<br />❑YES NO j❑ PROBABLY 0 UNKNOWN
<br />2
<br />14b RELATIONSHIP'TO DEOEDENY:
<br />Spouse'
<br />16c. DATE
<br />•-September 20;:2023
<br />STATE -
<br />Nebraska
<br />170 Zip.Coda::
<br />688E1 .
<br />APPROXIMATE IN'
<br />onset'todeath
<br />20 Mlfnutes'.•
<br />r -'
<br />AL
<br />lung in the underlying cause given in PART),
<br />21b.IF TRANSPORTATION INJURY
<br />Mmmoperator
<br />. Passenger
<br />' ❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MED/OAL'EXAMINER
<br />OR' CORONER CQNTACTEIfT
<br />••
<br />.1 YES
<br />21C. WAS AN: AUTOPSY PERFORMEI??
<br />❑ YES ::' NQ
<br />21d, WEREAUUTOPSYFINDINGS AWAILARt
<br />TO COMPLETE -CAUSE OF DEATH? ' •
<br />DYES •.: ❑ NO
<br />e farm, street, factory, office building, construction a
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />• 24d. TIME PRONOUNCED DEAD
<br />*4a. 5n the it:esis of examination and/or investigation, In my opinles deetk sietirreditt
<br />•the tuna; date and place and due to the cause(s) stated. (Signature end'T tle): • •
<br />26a. HAS ORGAN QR TISSUE DON.ATIONBEEN CONSIDERED?
<br />® YES 1:1VO::,
<br />NAME, TITLEANDADDRESS OF CERTIFIER (Type or Print
<br />l#nt)1Dny. Cook; NID, 2620 W Faidley Ave, Grand Island, Nebraska,.688
<br />28a. REGISTRAR'S. SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a1s NO YES
<br />28b. DATE FILED BY REGISTRAR (Mo Day Yr) .:
<br />September 26, 2023`;
<br />
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