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<br />)I STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CEPTIF/ES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OFTHE 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 />DATE OF ISSUANCE
<br />2/11/2022'
<br />LINCOLN, NEBRASKA
<br />Amended
<br />"Ill4, CITYAND:STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />20240485.
<br />4 &Glel
<br />SARAH BOHNENKAMI'
<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. DECEDENI"S N 44 :(lrst, Middle, Last, Suffix)
<br />Jannart :.Eliaabett McLellan
<br />Norfolk, Nebraska
<br />7. SOgAL SECURJT :: NUMBER
<br />607..60-5284
<br />8b:<FACILITY NAME (vent institution, give street and number)
<br />Grand Island.Regional Medical Center
<br />8o CITY ORTOWN 0F`DEATH (Include Zip Cods)
<br />Gran island::;88803
<br />9a. REtiIDENCE.STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sat AGE - LBat Birthday'
<br />(Yrs.)
<br />70
<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 :i Inpatient
<br />❑ ER/Outpatient
<br />:94(• STt EET AND NUMBER
<br />1605 Allen Ave
<br />1Oa. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />to :if.FATHER'SNAME Firiyt, Middle, Last, Suffix)
<br />tawrBncB L18Ife1d
<br />13; EyERtN t18 ARMED'PORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No •
<br />ar
<br />15. METHOD OF DISPOSITION
<br />13uriel ❑ Donation
<br />Cremation ❑ Fniombment
<br />©
<br />Removal 3 Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />22 00769
<br />3. DATE OP DEATH (Med Dtiyt>t;,)
<br />January 1t 2t)22
<br />8. DATE OF BIRTN (Ma, Day; Yr.)
<br />March 22 .0
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Harte
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Oe. APT. NO.
<br />18b. NAME OF SPOUSE (First, Middle, Last,
<br />William Lee McLellan
<br />9 12.5110THER S•NAME (First, Middle,
<br />I[ Frances Wemhoff
<br />9f. ZIP CODE
<br />68803
<br />9g )N$tDE0Y'LIMITS,:
<br />'YES ❑' NO
<br />Suffix) If wife, give maiden nierte :
<br />14a. INFORMANT -NAME
<br />William Lee McLellan
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO,
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AH Faiths Funerat Home. 2929 S. Locust Street, Grand Island Nebraska
<br />Maiden Surname)
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART!. Enter the chain of events. shamans, injuries, or complicationsdhat directly caused the Wath. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory arrest
<br />IMk'IEDIATE CAtd$i: (ptniil
<br />d seaes ar koneljfen tmsulthlg .'
<br />Initeathl ..
<br />Sequentially list conditions, if
<br />any, Iew.mg tQ.thecatree.iiited
<br />on�linea :
<br />1818100141,11 011318, i3CAUSl
<br />(distil e:or hijilieihat Iniffsfed
<br />the events resulting In death)
<br />'LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Multiple lung nodules, metastatic disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 'PART II' OTHER StGNIFtCANT CONDITIONS -Conditions contributing to the death but not rseuti ng In tit# underlying cause given In PART 1.
<br />NetlrttendoAe tutnor, metastatic malignancy to liver and spine
<br />20. IF:FEMALE'.::.
<br />11 Not Pr+gn4Mw#.*:0i tyaar
<br />Pregdint a4tbW W Wsttt
<br />❑ Npt fegnstd, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before Wath
<br />.Unknown If prsgnent within the past year
<br />22a'; CATEcOF;:INJURIY:(Mo 3Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑. YES ❑ NQ....
<br />21a. MANNER:OF DEATH
<br />Natural 3 Homlclda
<br />0 Accident ❑., Padding
<br />0 suicide Invut)gasuicide❑Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION Of INJURY':'. STREET & NUMBER, APT.NO.
<br />233. DATE `DEATH (Mo., Day, Yr.)
<br />January 11, 2022
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />J4IDUatV 21; 2022
<br />3A Tq the blit of en knowledge, death occurred at the time, date and place
<br />and dtibto the dlun(a) stated. (Signature and Title)
<br />Jose Belo APRN
<br />23c. TIME OF DEATH
<br />04:30 AM
<br />28. 13113 TOBACCO U$E:CONTRIBUTE TO THE DEATH?
<br />PROBABLY ® UNKNOWN
<br />21p:>IF:TRANSPORTATION INJURY
<br />Dr tetrOperator
<br />3 Pas#anger
<br />❑'tsadestrian
<br />❑ Other (Specify)
<br />home,;
<br />14b. RELATIONSHIP TO`$t&eibeNT.
<br />Spouse .
<br />18c, DATE IMP„ Day. Yr
<br />Janus nil 2022
<br /><isrATE
<br />Nebraska
<br />trio. Etp:C
<br />688
<br />APPROXI MATE INTERVAL
<br />Dries(t4d0? t
<br />Q1/090)22.4A))1/1
<br />t11/1
<br />•
<br />onsst.to:deeth
<br />01/08/2022
<br />onsetto death
<br />1!. WAS MEDICAL EXAMINER
<br />OR CORONER:CONTAGTEED?
<br />❑ YES kiNO
<br />21c. WAS AN AUTOPSY PERFORMS
<br />❑ YES NO
<br />21d. WERE AUTOPSY FtNDINGB AVAILAt
<br />TO COMPLETE CAUSE OF DEATH?.
<br />0 YEE 3i;)i0 ..
<br />trm street, factory, office building, construction site #tt ;gpaa(Cy)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day,Yr.)I
<br />24b. TIME OF DEATH
<br />Z1P;CC DE
<br />24d. TIME PRONOUNCED: DEAp;. ;,
<br />2 te.'im Ms basis of examination and/or Investigation, M my opinion 410114..
<br />the time, date and place and due to the cause(s) steak,. (aignetuta Mt(ti'tttle)
<br />26a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />0
<br />0 YES Ea NO
<br />21 NAME,'IITLE RD ADDRESS OF CERTIFIER (Type or Print
<br />Jose Bajet APRN 3533 Prairieview, Grand Island, Nebraska, 68803
<br />(3 YES
<br />28a. REGISTRAR'S SIGNATURE
<br />■•
<br />•
<br />Amended
<br />2/11/2022 Item 16c November 15, 2022 To January 15, 2022
<br />a-14_17 8.41,4.2.-nkoz-rkty
<br />28b. WAS CONBEN4 GRAN'
<br />Not Applicable if 26a Is NO
<br />28b. DATE FILED BY REGISTRAR (M0., 0
<br />January 21, 2022
<br />, Yr.)
<br />
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