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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL�I A1�fD HUMAN S�RV.�ES, I7" CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�K6�,�3�P�41:�A�F��V OF 11�TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FC?R v I��T�!{� ��t�Q DS ., ��ti
<br />'� - ° . . . � , � � �f.
<br />DATE OF ISSUANCE V a; � • � � _ � � �.�F '
<br />� STi9NEEY S: C.D9�R � : �`
<br />08/09/2011 �'�I��ISTAi�1( ,T STATE RE�l'S� 1 � (��, �
<br />�, 0 i i 0 G 5 01 _� s �JE@ARTNfiE�N�OF.HE� TH A. �� •.
<br />LINCOLN, NEBRASKA N(�h9xIN 3`�RVT�C�S°�,, _: ,� .
<br />` ,s-� �,t . r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S . y�, �°�t *� �. ��` .� - 'I 1 02615
<br />CERTIFICATE OF DEATH � ' �, �. A � ��r`� �,°��,. _��'� ..�
<br />1. DECEDENTS-NAME (First, Mlddle, Last, Suffiz) ' 2 Sa� f$ °1 �� � i � Augu� 5 2011Mo., Day, Yr.)
<br />Marsha Lea Medbery Femal� ;, P �
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY '�B �DA7E OF BIRTH (Ma., Day, Yr.)
<br />n'�•) MOS. DAYS HOURS' IWNS.
<br />York, Nebraska 63 Aprll 6,1948
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />50&60-7881 osLi.?� ����aaUeM OTHER ❑ Nursln8 Home/LTC � Hosptce Facllliy
<br />8b. FACIIITY•NAME pf rrot IrreUtutlon, glve street and number) � ERlOup�aUern ❑ Decede�rt's Home
<br />�
<br />� Saint Francis Medical Center ❑ ooa ❑ otn�r�spe��ry►
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<br />� Bc. CIIY OR TOWN OF DEATH (Include Zip Code) Bd. COUN7Y QF �EATH
<br />c Grand Island 68803 Hail
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREEf' AND NUMBER 8e. APT. NO. 8L LP CODE 9g. INSIDE CITY LIMOTS
<br />� 1817 W.John St 68803 � v�s ❑ No
<br />.$ 10a, MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Marrled 10b. NAME OF SPOUSE (First, Mlddle, Last, SuftUc) If wi(e, giva matden mame
<br />� ❑ nnamed but separated ❑ vsnaowea ❑ oworcea ❑ unknown George Ray Medbery
<br />� 11. FATHER'S•NAME (Ftrst, Middle, Lasy SuHbc) 72. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />Lyle Peterson Edith Doremus
<br />°' 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP 70 DECEDENT
<br />E
<br />$ �res, No, or Unk.) NO George Medbery Husband
<br />� 15. MEfHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 76b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />�? ❑ Burlal ❑ Donation
<br />Not Embalmed August 5, 2011
<br />� CremaUon ❑ Entombme� 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specffy) �ntral Nebraska Cremation Servlces Gibbon Nebraska
<br />17a. FUNERAL NOME NAME AND MAILING ADDRESS (Streef, Clty or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructlons and e�ca►n les
<br />18. PART L Enter the chaln of eveMS-riisaasea, lnjuries, or compticaUona4ltat tllrecUy mused the death. DO NOT e�er terminal eva�rts euch as eardlac artest, ; APPROXIMATE INTERVAL
<br />resplrstory artest, or veMricular flb�tllatian without ahowing the etlology. DO NOT ABBREVIATE. EMer ody one cause on a Iina. Add atldiGonal Iirrea B neceseary.
<br />IMMEDIATE CAUSE ; o�et to death
<br />IdIdIEDIATE CAUSE (Flnal e) Bowel Obstruction ; Days
<br />tlisea� or contlttlon resuitlng
<br />�� d �� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�,�.�aeur u� wm+nw�e, e b) Metastatic Adenoc�rcinoma of the Colon : Months
<br />arry. leatling to the cauae Iisted
<br />on Ime a DUE TO, OR a3 A CONSEQUENCE OF: ' onset to death
<br />E(rte�the UNDERLYINO CAUSE C �
<br />(disea� or injury that initlated
<br />the eve�rte reaWUne In ueath) DUE TQ OR AS A CONSEQUENCE OF: � orreet to death
<br />� d)
<br />18. PART 0. OTHER SIGNIFlCANT CONDITIONS-CondlUons conMbudnp to the death but not r�ulUnq in the underlying cause given in PART I. 19. WAS MEDICAL D(AMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />� � Not pregnairt w(thin past year � Natural � Homldda � DrivedOperetor
<br />� � PBe� m eu� or a�sn p a�aem � Pendln8 Inveati9atlon ❑ P�nee� � ves � No
<br />� Not pregnant, but pregnaM wfthin 42 tlays oi death gWdde Couid not be determined ��P�e�" Z� tl. WERE AUTOPSY FINDINGS AVAILABLE
<br />.� ❑ ❑ TO COMPLETE CAUSE OF DEATH7
<br />'Q � NM pregnaM, buf pregnaM 49 days to 1 year before death � Other (Speeiy)
<br />m � Un�mown ft Piee�t wtth�n the Pest year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) Ylb. TIME OF INJURY 22c. PLACE OF INJURY•At home, tarm, atreet, factory, offlce bullding, corw6vction ske, etc. (Specffy)
<br />E
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<br />.� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � August 5, 2011 ,� � �
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME QF DEATH �' k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNGED DEAD
<br />$� o Au ust 5, 2011 04:53 AM �' y a Z
<br />� . To the bask of my Imowledge, daath oceurted at Ne drtm, date and place $ �Z � 24e. On the baels of examinadon and/or investl8adon, In my opinlon death occurted at
<br />� o and due to the cauae(s) smted. (StgnaWre and TiUe) ��$ the tlme, tlate end placa and due to Ure cauae(s) afa0ed. (Slgnature and TIUe)
<br />~� Jay C. Anderson, MD '" g;
<br />25.'DID TOBACCO USE CONTWBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable ff 26a is NO ❑ YES ❑ NO
<br />2.' , T TL D DR OF CERTIFlER (PHYSIC , 1 ASSISTANT, ORONER S P YSIC R C ORNEI� (Type or rrt
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. pATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />August 9, 2011
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