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STATE OF NEBRASKA
<br />A'!�)ii'ttlt9iypd Wide.>; � ,zsH7,h111n r"f11D5@p,z�>es2.yir4y4'dpsas.,: ::. sigi6Gtn' ryVppgu.>• .::
<br />s2zGrt4W„m If'i'ib!�r 4/41,411i1sNs1
<br />WHEN ' #S COPYCARRIES ..THE RAISED SEAL OF STATE OF/NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW T+
<br />BE A`:TRUE .;COPY OF THE ORIGINAL RECORD ON FILE WITH"THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />Ht AIM SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />SARAH BOHNENKA14iP "
<br />ASSISTANT STATE REGISTR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />t:;DEC( DHltTt;+.NAME (#rhst, ; Middle, Last, Suffix)
<br />Marvin AKA,,M John Bailey
<br />ANO STATE OR TERRITORY, OR #FOREIGN COUNTRY OF BIRTH
<br />ns Nebraska ...
<br />sticti!OTT NUMBER
<br />etitn>4IIat. •H:oty?�#81
<br />Ic CtrY Oa.TIl ill
<br />Omaha 681d4
<br />9b. COUNTY
<br />Douglas
<br />E OF OATH Ed Married 0 Never Married
<br />0 Widowed ❑ Divorced ❑ Unknown
<br />7!y ATHEretEoNAME `(Flue, ....,_f
<br />Itef
<br />CLEVER IN U.S. AR IED FORCE
<br />(Yes, No,.or 40k.) Na.
<br />a1 ❑ Ehn•r (EPeolfy)
<br />data. of service If Yes.
<br />6a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />(Yrs.) MOS.
<br />83
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient
<br />❑ ER/Outpatient
<br />❑DOA
<br />9c. CITY OR TOWN
<br />Elkhorn
<br />2. SEX
<br />Male
<br />6c.UNDER 1 DAY
<br />HOURS
<br />3. DATE,OF,OEA/NOTI . or,4*(.)
<br />January 31,, 2028
<br />e. DATE OF A1kTH. (Mo., Day, Yr )
<br />November 2&.:1
<br />OTHER ❑ Nursing Home/LTCi
<br />❑ Decedent's Honk
<br />❑ pRy' mr.'e` lfy) - -
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68022
<br />10b. NAM OF SPOUSE (First, Middle, Last, Suffix) If wife, give Meilen it
<br />Carolyn J Reynolds
<br />( F `
<br />12, MOTHER'S -NAME (First, Middle, Maiden Sum.m.)
<br />Darlene Emma Spickelmier
<br />14a. INFORMANT -NAME
<br />Carolyn J Bailey
<br />tea. EMBALMER -SIGNATURE
<br />Andrew D Purcell
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Valley Cemetery
<br />16b, LICENSE NO.
<br />1486
<br />NERAL,HCME:NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br />penter'Brelefid: Funeral Home, 305 W. C Street, PO Box 476, McCook, Nebraska
<br />KI! RTlttitte'tthsalydiraf;
<br />iMtPffal?ry.r1!!sM4. tx vfHp
<br />ifM1DIATE CAUIE
<br />dla n-or PI
<br />CITY / TOWN
<br />Maywood
<br />CAUSE OF DEATH (See instructions and examples) • •
<br />like, le1)trsise, or complications4hat directly caused the death. DO NOT enter tarminatevents such as cardiac arrest,
<br />Morr,waheutshowing the etiology. DO NOT ABBREVIATE,. Enter only one cause on a Una. Add additional lanes N necessary.
<br />IrATE CAUSE:
<br />'is with septic shock
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />rime , b)Cl idium septicum
<br />i OR AS A CONSEQUENCE OF:
<br />Ft re colitis
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />t1)Constipation
<br />i8 PART:IL OTFIEp $lG t tCAttT CONDITIONS -Conditions contributing to the death but not resulting ht etc underlying cause given In PART 1.
<br />Systemic mastocytosls, myelodysplastic syndrome, hypertension, hypeilipidemia, ischemic cardiomyopathy, chronic kidney
<br />disease, prostate cancer, type II diabetes mellitus
<br />. IF:P M 0 ,
<br />ta1n1 t-:
<br />t /lagntr4, hsl pregrenn whhio a2 d
<br />tprynint, but Prsgi,*43 dote to
<br />known 1 pregnnnt'+�it iin the past yt
<br />A TI
<br />fore death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ PendinElnvwttgation
<br />❑ Suicide ❑ Could not be (*hymnlike
<br />alb. IF TRANSPORTATION INJURY
<br />❑ Ddver/Oparstor
<br />❑ tit tionger
<br />❑ Pedestrian
<br />❑ Other (Specify) ._
<br />19: WAI
<br />OR C±C
<br />O YE$
<br />21e. WASAN,/WTOPaYP
<br />-❑ / YES
<br />21d. WERE AUTO
<br />TO COMPLETE
<br />❑ YES'
<br />day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At.bome, farm, street, factory, offlcs butiding, construction
<br />222s. DESCRIBE HOW INJURY OCCURRED
<br />BER, APT.NO.
<br />23a. DATE, OF DEATH;(Mo., pay, Yr7y
<br />January 31, 2025
<br />21<ba HATE SIONED:)Mo., D4y.
<br />Fe :...:...ryryO
<br />3d..T.o tit a basi of mtj kn4 deatir oacurnd at the time, date and place
<br />end TUIs)
<br />CITY/TOWN
<br />Brit:(
<br />YES ::.M,,,.:
<br />i>E A
<br />h
<br />23o. THE OF DEATH
<br />11:39 PM
<br />Sher, M6
<br />*ISU'TE 1-0 THE DEATH?
<br />©:PRSteAeLY ❑ UNKNOWN
<br />ESE OF CERTIFIER (Type or Print
<br />her, MD, 8303 Dodge Street,( Omaha, Nebraska, 68114
<br />. 1.1wPr't;),.0-, 0
<br />0
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr,)
<br />24b. TIME OF
<br />24d. TIME -
<br />TM. 0n the basis of examination -and/or Investigation, In ray
<br />the tin., ate and place and due to the cuss(s)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ Is Igi NO
<br />26b. WAS CON
<br />Not Appl ce6ie If
<br />26b. DATE FILED EY RE
<br />February 7, 2025
<br />
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