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<br />( 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 />BE A TRUE COPY OF me 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 />1
<br />;GATE OF ISSUANCE
<br />11/1012f�1'
<br />LINCOLN, NEBRASKA
<br />1• DECEDENT$ t1AME {FIrst, Middle, Last, Suffix)
<br />Marcus ietycle third
<br />202606.663
<br />141 /7 &1 dtL11
<br />SARAH BOHNENKAMP
<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 />4. CITY AND STATE Olx TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Keamey, Nebraska
<br />7. SOCIALSEOURITY NUMBER
<br />506-66 5570 •
<br />Sb. FACILITY NAME(ff riot Institution, give street and number)
<br />CHI Health St. Francis
<br />5c. c Y OR TOWN OF'DEATH (Include Zip Code)
<br />Grand istand 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />,.,
<br />711 West;6th Street:
<br />9b. COUNTY
<br />Hall
<br />10a. MAR:Et7AL #1I'ATIN AT4IME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER&NAME (First, Middle, Last, Suffix)
<br />John CFyde Hird<
<br />13.`EVER:.IN U;$ .ARMED;FORCES? Give dates of service if Yes.
<br />(Yee, No, or sank.) Yes Dates Unknown
<br />5a. AGE - Last Birthday`
<br />(Yre.)
<br />69
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa. PLACE OFDEATH
<br />HOSPITAL ®inpatient
<br />[] ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 15066
<br />3. DATE OF DEAThI (Mitt.,, pay YF).
<br />November 2..2021:::.;
<br />6. DATE OF BIRTH Mo., bey.Y'r.)
<br />June 30, 1::9.52 >:..
<br />OTHER 0 Nursing Honae/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />pace! Fl *
<br />:.Iooute.CITY ITS:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Janet Daniel
<br />112. MOTHER'ENAME (First, Middle, Maiden Surname)
<br />Freda Waits
<br />14a. INFORMANT -NAME
<br />Janet Hird
<br />15. METHOD OF DISPOSITION
<br />❑ E uiiafl. ., ::: 0 Dorlet on
<br />;C►ematitte flentont rant
<br />❑ Rsmovel ❑ Ottior (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSItIY TO DE6EbENl :>;
<br />Spouse
<br />19c. DATE(into., Diy. Yr.):r
<br />November. 3, 202t;..:
<br />Nebraska
<br />17a. FUNERAL HOME, NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instruction*and examples)
<br />1a. PARTV. EnterMr/chainn Prevents- diseases, Injuries, or compllutlone.that directly caused the death. DO NOT entertsnninel events such as cardiac arrest,
<br />respiratory arrest, or ventr$culer 4NAMation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />INMENATESAVORIFIPS:<::. B)Colon Cancer
<br />dls ales or anti? on reauainq
<br />In daeott DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially get conditions, If b)
<br />.. any. leading to the cause pond
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Erilprlh UNDE I.YI ,KibAU8E' O)
<br />(WN111lrx:W ityu4dtathl(Lf4(+Wl
<br />the "erns rasa" in dseth) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAaT.. ._ d)
<br />16 PART II OTHER S1GN)F)CANT CONDITIONS -Conditions contributing to the death but not resulting in the. Underlying cause given in PART I.
<br />20 IF FEMALE' .
<br />Not 91lgnalit wthin pW yMr
<br />:PrWn►M ai lain" hf death
<br />❑'NetprrlptfrR; but aragnanl within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Q 4nknown If. prgnaptiothin tM past year
<br />22a.DATE
<br />•)F INJIJRY(Mu1 Day, Yr.)
<br />22d. INJURY At WORK?
<br />❑ YES ONO.. .
<br />21a. MANNER OF DEATH
<br />® Natural ❑::Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />.21b IF TRANSPORTATION INJURY
<br />❑ DnVer/Operator
<br />❑ Pldestnan
<br />❑ OtMr (Specify)
<br />170. 22p:Code
<br />=68801 •
<br />APPROXIMATE INTERNAL
<br />onset to death
<br />onset to d.ath
<br />19. WAS MEDilAL:EXAMINER
<br />OR CORONERSONTACTE0?
<br />❑ YES NO
<br />21c. WAS AN AUTOPt5Y P,
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAltABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑.::ND
<br />22c. PLACE OF INJURY -At home, tamer street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY .STREET & NUMBER APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 2, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 2, 2021 05:14 AM
<br />(3d Ts i * bent Af niy.knowledge, death occurred at the time, date and place
<br />sl)d this td thez,/usspl ststsd. !signature and Trtie)
<br />Douglas Herbek, MD
<br />u6
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />CODE::
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />814
<br />24d. TIME PRONOUNCED DEAD
<br />.he busie of examirutlon and/or investigation, In my opin
<br />litre dab and plan and due to the camels) stated. (Signature any T
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO. ❑ PROBABLY ® UNKNOWN
<br />37. NAME, linfitimi ADbFESS OF CERTIFIER (Type or Print
<br />Douglas Fterbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES :.
<br />25a. REGISTRAR'S SIGNATURE
<br />a-2ail
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 8, 2021 ti
<br />W
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />
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