|
STATE OF NEBRASKA
<br />tt.GhhLM�cc 4>_,�`?aa2gG01'I'CCI;P.1101�ct ,`; �•
<br />::<•dGG'I'l.'I:IA.10C1Jys,'; _;..;,�ezrrgriVdSsr.
<br />PY CARRIESTHE RAISED SEAL OF STATE OF,NEBRASKA,'IT CERTIFIES THE DOCUMENT BELOW TO
<br />F THE ORIGINAL, RECORD ON FILE WITH"THE•'NEBRAS]KA DEPARTMENT OF HEALTH AND
<br />ES/ VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />i>'TB OF!S$U
<br />.V10/2025'
<br />s.
<br />202503289
<br />SARAH BOHNE
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF REALTI
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE •QF DEATH
<br />,EDENr s E' (Ftrittig.Mlddl., Last, Suffix)
<br />John Bailey -AKA M John Bailey
<br />TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />(SOCIAL SL ilR TY NU BER i
<br />0648'73::<:::
<br />lib. FACILITY
<br />Nebra*. Nlethodist:.H
<br />4:
<br />Ik1: RESIDENCE;1i'rA
<br />.:Nebraska
<br />AN
<br />0
<br />1 FA Oft.
<br />mi
<br />N
<br />D.EA'Fft Ri
<br />418404.
<br />11 St
<br />ill
<br />give street and number)
<br />i 11Et IN'U.b. JARMED`FORCEs? ,Gt
<br />(Yes, No, orUnk.). No
<br />f#.,METhtf ti DISPOSITION:::
<br />6.urial aiii*pri,C30#00041‘t nto t
<br />QlRemoval '❑'Other(Speclfy)
<br />e)
<br />9b. COUNTY
<br />Douglas
<br />Married 0 Never Married
<br />Divorced 0 Unknown
<br />Last, Suffix)
<br />of service If Yes.
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />83.....::::
<br />Sb: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />Oa. PLACE OF DEATH::;
<br />HOSPITAL Ea inpatient
<br />0 ER/Ou patient
<br />p 0oa
<br />9c. CITY OR TOWN
<br />Elkhorn
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo ,;Day' Yr.r`,
<br />January 31:, 2r<
<br />OTHER ❑ Nursing Homs/LTO.
<br />0 Decedent's Hems
<br />0 tarM,.pe
<br />Ied. COUNTY OF DEATH 7
<br />Douglas
<br />Bad: APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last
<br />Carolyn J Reynolds
<br />1 12;:MOTHER'S44AME (First, Middle, Maiden
<br />Darlene ... Emma Spickelmier
<br />14a. INFORMANT -NAME
<br />Carolyn J Bailey
<br />15a, EMBALMER -SIGNATURE
<br />Andrew D Purcell
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Valley Cemetery
<br />NERA£ trtdm NAME: tiND MAILING ADDRESS (Street, City or Town, State)
<br />tsnter;;Br+ landFuesral Home, 305 W. C Street, PO Box 476, McCook, Nebraska
<br />1614. LICENSE NO.
<br />1486
<br />Ti
<br />ury that;
<br />tilting 'kr
<br />9f. ZIP CODE
<br />68022
<br />Suffix) If wife, give
<br />CITY / TOWN
<br />Maywood
<br />CAUSE OF DEATH (See instructions and examples)
<br />in)urtia, or complicaaons4hat directly caused the death. DO NOT enter temdnat*vents such as cardiac arrest,
<br />9Natian without shoring the etiology. DO NOT ABBREVIATE,Enter only one cause on a line. Add additional Tines If necessary.
<br />tMMEDUtTE CAUSE:
<br />Sepsis with septic shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Ctosstridium septicum
<br />OR AS A CONSEQUENCE OF:
<br />re colitis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Constipation
<br />ART IL..QTHERR. GNIFICANT:CONDITIONS-Conditions contributing to the death but fiat n»tilting itt the and rtying cause given In PART I.
<br />,te to riiastocytosis, myelodyspiestic syndrome, hypertension, hypertipidemia, ischemic cardiomyopathy, chronic kidney
<br />e#1ses, pros t+ cancer, typeIldiabetes mellitus
<br />DATE OF I ttli (Me ,Day, Yr.'
<br />INJURY AT WORK? 22e
<br />21e. MANNER OF DEATH ..::.
<br />® Natural 0 Homkide
<br />0 Accident ❑ Pending invut(tmfen
<br />0 suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />HOW INJURY OCCURRED
<br />APT.NO. CITY/TOWN
<br />a. DAtEC)F DEATH(MAo.,Day, Yr.(
<br />January. 1, 2025
<br />b.DATE:SIGNED (Mo., pay, Yr.) 23c. TIME OF DEATH %
<br />'eBTO 6...P.' . 11:39 PM
<br />dT . #r:llts:t?on or inirxen 6000 occurred et the time, date and place
<br />:::i,s:�nd den�1A t1N; caU.s(►tat.d. i#ioneture anti Tak)
<br />2114. IF TRANSPORTATION INJURY
<br />OdverlOp rstor
<br />. L7libsw'00,.+r
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />146 R*C
<br />Sp
<br />1ec. DATE,(M0.}iSf
<br />Febrilery T, 2p25
<br />19,.ii1tA2
<br />21c. WAS ANAUTOPSr'#;PEttFt]1i
<br />DYES • 1#tt " '=`.' : _`
<br />21d. WERE.AI,ITC
<br />TO COUPLE
<br />❑ yes
<br />rm, street factory, office building, construction
<br />STATE
<br />24s. Oh lire bl i cf examinadoatnd/or Imem(gaaon, In toy opeilon
<br />the time, date and place and due to the cause(a) staled. (aiplb't
<br />.t:G U 4"Qt»TiIM1Ta TO THE DEATH?
<br />{:;NO '% <P ROBABLY ak UNKNOWN ❑YES NO ..;
<br />7IThE ANDADDRESS.OF CERT)Fi it, (Typo or Prim
<br />r
<br />lei Oebri eegzabeher,.MD, 8303 Dodge Street, Omaha, Nebraska, 68114
<br />TRARI SIGNATURE .
<br />25a. HAS ORGAN. on Ileum immix* BEEN CONSIDERED?
<br />2eb. WAS oCiNsE1Ili t
<br />Not Applicable If tea is NO
<br />
|