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<br />STATE OF NEBRASKA,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE. P `"
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY h�,
<br />DATE OF ISSUANCE
<br />202500408 A A.
<br />DEP7i4/
<br />LINCOLN, NEBRASKA HUIN�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESt
<br />CERTIFICATE OF DEATH
<br />11/29/2012
<br />TIFIES
<br />To be completedNerified by: FUNERAL DIRECTOR 1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Lloyd Dean Marshalek
<br />2. SEX
<br />Male
<br />. DA TR IMO. Day,1R.)
<br />'Wtiifllsr 16, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.) ,
<br />Loup City, Nebraska
<br />(Yrs.)
<br />68
<br />MOS.
<br />DAYS 1
<br />HOURS
<br />MINS.
<br />February 7, 1944
<br />7. SOCIAL SECURITY NUMBER
<br />508-54-2964
<br />8a. PLACE OF DEATH
<br />tignm 0 Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (I not Institution, give street and number)
<br />Saint Francis Medical Center
<br />El ER/outpatieM 0 Decedent's Home
<br />p DOA ❑ Other (specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />; r 4-
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ell. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island ,
<br />ad. STREET AND NUMBER
<br />922 East 14th Street
<br />tie. APT. NO.
<br />W. ZIP CODE
<br />68801
<br />S,
<br />lg. F1310E'CITY LIMITS
<br />®'YES C( � tO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed Q Divorced 0 Unknown
<br />10b. NAME OP
<br />Sharon
<br />SPOUSE (First, Middle, Last, Suffix) I wife, 4Iue maiden name
<br />Berson L
<br />j a
<br />11. FATHER'S -NAME (Find, Middle, i Last, ... Suffix) .
<br />Dominic Marshdlek
<br />Mmdte�niden Sarno nrer _._
<br />12. NNi jt•tie! , Ilil�'
<br />Victoria Shuda
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service I Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Sharon Marshalek
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse '�, -
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />18a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />18b. LICENSE
<br />1328
<br />NO.
<br />16c. DATE (Mo., Day,,*.(
<br />November 21, 2012`
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CRY/ TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Cods
<br />68801
<br />t
<br />CAUSE OF DEATH (See instructions and examples)
<br />To becompleied by: CERTIFIER
<br />1s. PART I. Enter the Quoin of eventS-•dlaeases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br />resplratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines N necessary.
<br />IMMEDIATE CAUSE: I onset to death
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease Years
<br />disease or condition rewriting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: *nest to death ''
<br />i Sequentially Nat conditions, N b) Left -sided Rneumonia ; 2 Weeks
<br />any, leading to the cause listed
<br />on line a DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Sepsis
<br />(disease or Injury that Initiated.
<br />onset to death
<br />2 Weeks
<br />... . .
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Non -Hodgkin's Follicular Lymphoma -
<br />onset to death
<br />7 Years
<br />18. PART II. OTHER SIGNIFICANT COMITIONS-Conditions wMrlbutIng to the death but not resulting in the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. (F FEMALE:
<br />❑ Not pregnant within per year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Pa aenger
<br />21c. WAS AN AUTOPSY PIRiFORMED?
<br />❑ YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />❑ unknown If Pregnant whhin the pact year
<br />❑ Sundae ❑ Could not be dwen reined
<br />....
<br />❑ Pedestrian
<br />0 Other ISwoNy)
<br />-
<br />21d. WERE AUTOPSY FINDINGS;AV ILAILE.
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, farm, street factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />1
<br />a
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Ic
<br />'
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />November 20, 2012
<br />(1
<br />24b. TIME OP DEATH
<br />08:55 PM .y��
<br />I
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />I
<br />iE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 16, 2012
<br />24d. TIME PRONOUNCES DEAD
<br />08:55 PM
<br />3 p
<br />F
<br />23d. To the best of my knowledge, Math occurred et the time, date and p�
<br />and due to the ause(s) stated. (Signature and Tide )
<br />1 a t
<br />Eopinion
<br />u°- �
<br />0 8
<br />24e. On aw basis of examination and/or investigation, in death andTA*calmed at
<br />the time, date and place and due to the canal) stated. Minster* and TAM)
<br />Sarah Johnson, Hall Deputy County Attorney
<br />25. DND TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />SSUE DONATION BEEN CONSIDERED?
<br />El NO
<br />23b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />27.'kAME , TITLE AND ADDRESS OF CERTIFIER (Type or Pr
<br />Sarah Johnson, Hall Deputy County Attorney, 231
<br />S. Locust, P.O : • Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE, A 17� ,f-
<br />air 1
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 21, 2012
<br />
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