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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 WOE COPY OP 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 />DIiTS O1 ISSUANCE
<br />4/11202 k
<br />LINCOLN, NEBRASKA
<br />20'240342�T s K&Is
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />11111•111111* 1. DECEDENT -NAME (First, ( Middle, Last, Suffix)
<br />. Marian Cecelia Augusta Walters
<br />4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />1
<br />3
<br />Ericson Nebraska
<br />CIAWSECURITY NUMBER
<br />'$06,4t-96.88
<br />8b.'FAC1LiTY=NAME (Itnat Institution, give street and number)
<br />CHl Health St. Francis
<br />tic. CITY Oft TOWN
<br />Grand island:
<br />of DEATH.(Include Zip Cods)
<br />0s. RESIDENCE -STA`
<br />Nebraska
<br />e4 STREET ANP. NUMBER
<br />50� E 12th St
<br />9b. COUNTY
<br />Hall
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />2404285
<br />3. DATE OF DEATH (Mo Day,Yr )
<br />March 18,.2024
<br />6. DATE OFBIRTI!I'IMo., DeyyYt:)
<br />83
<br />6s.:PLACE Oi :DEATH`
<br />elOSPITAL ]$j'teoafient
<br />p ER%Outpatient
<br />Octo•er7.::1
<br />0 DOA
<br />19e MARrrALSTATUS:AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Marred, but separated 0 WidowedIi1L Divorced 0 Unknown
<br />14 FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Paul Johnson
<br />EVER(N U S ARMED:FORCES? Give dates of service if Yes.
<br />(Yes, No, or tfnk) No
<br />18. METHOD OF DISPOSITION
<br />O; Burial RiCIOOPOP.on
<br />Cremation p Entombment
<br />Raenittw0 pternir(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />p Other (Spey)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />6e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g i OEcr .:.t.Mrrs
<br />I Yes ONO
<br />lob NAME OF SPOUSE(First Middle, Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT NAME
<br />Cindy Crossmore
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER S.NAME (First, Middle, Maiden Surname
<br />S Cecelia Hardy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />11s. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State).
<br />All Faithsuneral Home, 2929 S. Locust Street, Grand Island, Nebraska for
<br />Other t pDify)
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See :>InStructlolts And examples)
<br />it. pAR`r i. Enter tits chain ninon neatens, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation Without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />04919,01A11 0903E a)cardiorespiratory failure
<br />amiss Or 04101on ria dthlt .. .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Methuen* Hat conditional, b)Thoracoabdominal aortic aneurysm with type A aortic dissection with evidence of rupture
<br />any, leading to the cause listed
<br />a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entwine LINDlUt,4.YINOCAl15E> - O)
<br />iditendd:orinjuR,rMet L; age
<br />the events resetting in dee" DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART II O'f'NER SIGNIFICANT CONDITIONS -Conditions contr€buting to the death but not resuttiig in the underlying cause given In PART I.
<br />Strperior Mesenteric aneurysm, Splenic artery aneurysm, Coronary artery disease,;Per€pherat Vascular disease, Obstructive
<br />sleep apnea, Essential Hypertension
<br />20. IF FEMALE:
<br />Not pregnai* whtdn pee* year
<br />Pregnant at tbhe of death:
<br />❑.;Not pnenan but pnri(natit whin 42 days of death
<br />D Not pregnant, but pregnant 43 days to 1 year before death
<br />:.. D Unknown if pregnant within the past year
<br />22* DATE OF:IN,IURY,(Mo'
<br />22d. INJURY ATWORK?
<br />41 DYES 0 N
<br />Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural l from kids
<br />0 Accident D Paadind Imaatigpdan
<br />❑ suicide 0 Coude not be deteirnln.d
<br />22b. TIME OF INJURY
<br />21b.I.F TRANSPORTATION INJURY
<br />;� DriverIOperator
<br />;© Pisiienger
<br />p Pedestrian
<br />0 Other (Specify)
<br />14b. RELATIONSHIP TO DECEDENT;:;
<br />Daughter
<br />18c. DATE (Mo.;Yr,),
<br />March 28, 4
<br />Nebraska
<br />Onset to death
<br />Hours To Days
<br />onset to death
<br />19. WAS MEfRCAi#E)tAMINBFt:
<br />OR CORtjNERCONTACTED?
<br />❑ yes in No
<br />21c. WAS AN AUTOPSY
<br />0 YES 1214"),.:
<br />21d. WERE AUTOPSY FNNDINGS AV&I
<br />TO COMPLETE tCAUSE OF DEATH?
<br />p YES W!NO
<br />22c. MACE OF INJURY,At home, farm, street, factory, office building, construct'
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />1.00101014.0F INJURY;;; STREET & NUMBER, APT.NO. CITY/TOWN
<br />Ia
<br />0
<br />23a. DATE OFDEATH (Mo., Day, Yr.)
<br />March 16, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 182024 09:40 AM
<br />TO N14 bent: of my Itnowiedge, death occurred at the time, date and place
<br />sae date tafthAt iusNe) stated. (Signature and Tits)
<br />Vertikata S Kanakadandi, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES :'® NO .0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24s. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH,
<br />24d. TIME
<br />tete. On the mins of examination andlor investigation, M my opinion death a
<br />the stns; date and place and due to the tansies) stated. (signstum acid?
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 14'
<br />U NO
<br />37. NAME, T'ITLi ANO 7ADi KESS OF CERTIFIER (Type or Print
<br />enkata Kanakadandi, MD, 2620 W Faidley Ave, Grand island, Nebraska, 58803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT RANTED?: .
<br />Not Applicable H 264 is NO YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr)
<br />March 28, 2024
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