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<br />C_ STATE OF _NEBRASKA
<br />Y41i99MAMla a?y�49trA'AltiiftDA3ty....:•.r`.SA6/449rtldrAxt.:..•e.- f.5Y64y. .1It6S�R'• .. ,zs59rwstsie'3.o.::E
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<br />/HEN fill$ COPY CARRIES •THE;RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />•
<br />EA TRUE CORY OF TtIE OR1GlN'IAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND • •
<br />lMANSERV/CES, VfTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202
<br />0632
<br />'IC"? or:WilVilicio
<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 pecgDENTS NA51F (1 E st Middle, Lest,
<br />• Marilyn ;Catherine )49iieller
<br />Suffix)
<br />r SIDDEAL SEcuAT I
<br />.607 80.897'4
<br />5a. AGE Lest Birthday
<br />(Yrs.)
<br />64
<br />8b. FACI)JTY NAME'(If
<br />CH4
<br />•8c CITY OR TOWN GF (Include Zip Code)•
<br />Grand Isia:nd 68803,
<br />9.a. RESibENCESTATE `.,
<br />Nebraska'
<br />Sd,;RTREET:AND NUM:pE
<br />1);O W Kgar►Jq
<br />10e'i ARtTAt TATUSAT:
<br />eperated
<br />11:"FRTHEFS,siAME (Firs
<br />Merlin S) aUkhns
<br />13. 0,$, ARME)FQ
<br />(Yes No, 01 '010 No
<br />9b. COUNTY
<br />Hall
<br />ME OF .DEATH 0 Married 0 Never Married
<br />idowed.: 0 Divorced 0 Unknown
<br />Y6.=METHODOF, DISPOSITION
<br />0 BunEtt) :. 0 Donation:.',
<br />®si3rtMat(pn
<br />(,�"Refnbvef
<br />Give dates of service if Yes.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL �] Inpatient
<br />® en/outpatient
<br />DDA
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS..'
<br />3: DATE OF DEA.:TH (Mo:; .pa
<br />November "AS. 2021..
<br />Yr;
<br />OTHER 0 Nursing •N
<br />0 Decedent's H
<br />Q Qther(Sp•ecl
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />•e Fagplty
<br />•
<br />NSI! EC3fYlilMIT$
<br />Bio :.
<br />1013: NAME OF SPOUSE (First,Middle, Last, Suffix) If wife, giv
<br />Lloyd Mueller
<br />14a. INFORMANT -NAME
<br />Lloyd Mueller
<br />16a. EMBALMER -SIGNATURE
<br />• Not Embalmed
<br />12. MOTHER'S -NAME (First,
<br />Phyllis Price
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />- ,Heafey-Hoffman-Dworak-Cutler
<br />11a FUNERAL'HOME NAME AND:MAILING ADDRESS (Street, City or Town, State) :.
<br />Apfei Funeral Home, 1123 W 2n'd Grand Island, Nebraska
<br />„16b. LICENSE NO.
<br />Middle, Maiden Sum
<br />141.'RELATIONSIiIP.Tool
<br />Spouse';
<br />16c DATE (Mo , t1A�r Yr.),•
<br />Nov¢rribei 1S 20
<br />CAUSE OF DEATH'(Se€ Jnstru
<br />"!b Zip G
<br />(iFlBi�.
<br />brit and examples) •
<br />rthR'Chain of events: diasaees, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ventricular fibneatiph without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if fleece
<br />IMMEDIATE CAUSE:
<br />Sudden:Ciirdlac death
<br />1MWtGtnATE DAt!&� ...
<br />disease or condition resulting:;
<br />In.deatlik; ; .
<br />�uernlairy list'Gondifioas:
<br />n,,teading ioliw..cause fisted....
<br />5nter ttte UNDER! YINO
<br />(diseaseior iaj..that.In
<br />:therevents'resbainp mn:d
<br />DUE TO,..OR A$ A CONSEQUENCE OF:
<br />)i;7nk0own
<br />DUE ,TQ, ;OR AS A CONSEQUENCE OF:
<br />HER SIGNIFICANTCONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in
<br />C?beslty •
<br />'20. K EMAI.E
<br />0
<br />:. Net preyrreat Within
<br />Pfegaatil aE tier, of d
<br />�+��+�J rt01 pragnapt,�but ptltgtisnt wthin.42'days of: death.
<br />Not Pregnant:
<br />Peltngwnlf ptegnaMwittyn the pest°year
<br />s •to 1year•before death
<br />DAT
<br />evl
<br />21a. MANNER OF DEATH
<br />® Natural Homicide
<br />0 Accident 0 Pending Investigati!
<br />0 Suicide El Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />21b, iF TRANSPORTATION INJURY
<br />0 t)nYar/Operetor •
<br />Passenger
<br />QPedestrian
<br />0 Other (Specify)
<br />•
<br />INJURY -At home,1
<br />CART t:'.
<br />19. WAS MEDNIA .EXAfilINE
<br />OR CORONER CQN:TA.:.
<br />{ YES:©)10',
<br />21c. WAS AN AUTOPSY P
<br />0 YES
<br />21d. WERE AUTOPSY MND1NGS AUA#IABLE
<br />TO COMPLETE:CAU$EOFDEATH? •
<br />,'street, factory, office building, constructionsite,
<br />INJURY STR
<br />3a DATE OF P
<br />'Noverriber
<br />NUMBER, APT NO
<br />H,(Mo.,.Day,
<br />021
<br />23b DA'TESEGNED (Mo Day, Yr')
<br />November 18 2021'
<br />CITY:
<br />23c. TIME OF DEATH
<br />06:57 AM
<br />29d Tpttnt beater my.knowledge, death.occurred at the time, date and place
<br />E'liillit..:ditiattillikdiUeelsystated.lialgaature and Title)
<br />Nicti`olas M EQx MD
<br />2a DIDTOBACCO:USE CONTRIBUTE TO THE DEATH?
<br />PROBABLY:.® UNKNOWN
<br />P.
<br />2�
<br />•
<br />U
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIM
<br />24d. TIME PRONOUI
<br />ED DEAD
<br />24e. On the basis of examination andtor investigation, in my optnion.death oicuriett.at
<br />Hie tial 'date and place and due to the cause(s) stated. (Signature and Tiflis);
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />27. NAME, T[TI EANDADQRESS OF CERTIFIER or Print
<br />f itholas..Oox, rep 2&20`. W.Faidley'Ave, Grand Island Nebraska, 68803
<br />28a.REGISTRAR S
<br />GNATURE'
<br />O-'24}? ii �t Zr
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26e is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 21 2021.
<br />
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