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qhfaratillabnlitraff STATE OF NEBRASKA WHEN THIS "'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 8/30/2017 LINCOLN, NEBRASKA 201706121 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Clop STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Phillip Carter ARTI. Enter the chain or events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiogenic Shock disease or condition resulting APPROXIMATE INTERVAL :s onset to death 3 Days 4, CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wood River, Nebraska 7. SOCIAL SECURITY NUMBER 505 -52 -6417 . tY e 8b. FACILITY - NAME (If not Institution, give street and number) CHt Health Nebraska Heart t k i 8c. CITY OR TOWN OF DEATH (Include Zip Code) 5 . Lincoln 68526 • 9a. RESIDENCE -STATE u Nebraska LL 9d. STREET AND NUMBER 210 West 12th St. .0 10a�.. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married Married, but separated '❑ Widowed ❑ Divorced ❑ Unknown E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. ✓ ( Yes, No, or Unk.) N O a, tL 20. IF FEMALE: a ❑ Not pregnant within past year V ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death • ❑ N o t pregnant, brit pregnant 43days to 1 year before death ❑ Unknown # Meanest withinthe past y ear E 22a. DATE OF INJURY (Mo., Day, Yr.) Z 22d. INJURY ATINORK? J YES [3 NO 15. METHOD OF DISPOSITION ❑ Burial 0 Donation E Cremation 0 Entombment Removal 0 Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska 230, DA'T'E SIGNED (Mo., Day, Yr.) September 23 2016 23c. TIME OF DEATH 03:08 PM 3d. To the best of my knowledge, death occurred at the time, date and place nod due t^ the cause(s) stated. (Signature and Title) Anil :lain, MD ; 23a. DATE OF DEATH (Mo., Day, Yr.) September 21. 2016 25. DID TOBACCO? USE CONTRIBUTE TO THE DEATH? ❑ YES Q NO ❑ PROBABLY E UNKNOWN 28a. REGISTRAR'S SIGNATURE 22b. TIME OF INJURY 5a. AGE Last Birthday (Yrs.) 76 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined E YES 5b. UNDER 1 YEAR MOS,_; DAYS 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ONO 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Lancaster 9c. CITY OR TOWN Wood River 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gwendolyn Janice Shiers 41. FATHER'S -NAME (First, Middle, Last, Suffix) D , John James Carter Jr 12. MOTHER'S -NAME (First, Middle, Gladys Deenier Maiden Surname) 14a. INFORMANT -NAME Gwendolyn Janice Carter 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION BML Cremation Service CITY / TOWN Lincoln STATE Nebraska 18. PART Ii. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY 0 DrIVer/Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 245, PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68883 3. DATE OF DEATH (Mo., Day, Yr.) September 21, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) June 4, 1940 28b. DATE FILED BY REGISTRAR (Mo., September 26, 2016 9g. INSIDE CITY :LIMITS • E YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) September 23, 2016 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) in death) Sequentially list conditions, if any, leading to the cause listed _; on line a. DUE TO, OR AS A CONSEQUENCE OF: b) Myocardial Infarction onset to death 3 Days Enter the UNDERLYING CAUSE (disease nr injury that initiated the events resulting •st death) • OAST DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21c. WAS AN AUTOPSY PERFORMED?. ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22€. LOCATION OF INJURY STREET& NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED D D 24e. On the basis of examination and /or Investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO Q YE E:NI 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Anuj Jain, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 y , Yr.)