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iv aid46 Fit C s 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 5/17/2018 LINCOLN, NEB RASKA 201803985 j STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH U. K W (.3 a E 0 u 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Charles Dennis Cantrell 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Arnold, Nebraska 7. SOCIAL SECURITY NUMBER 506 -60 -7992 8b, FACILITY -NAME (If not Institution, give street and number) Veteran Affairs Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE.STAT Nebraska 9d. STREET AND NUMBER 4342 Loveqrass Dr. 9b. COUNTY Hall Sa. AGE Last ) (Yrs.) 69 l irthday 10e. MARITAL ?STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lisa LeeAnn Krance 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lewis Cantrell 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Winifred Witthuhn 13. EVER IN U ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT - NAME (Yes, No, or Unk.) Yes; 12/20/1968- 12/14/1972 Lisa LeeAnn Cantrell 16. ME HO F DISPOSITION 16a. EMBALMER-SIGNATURE 14b. RELATIONSHIP TO DECEDENT Wife 1 44 O ❑'Burial 0 Donation Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo„ Day, Yr,) May 8, 2018 ® Cremation ❑ Entombment ❑'Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY/TOWN Gibbon STATE Nebraska 17a. FUNERAL NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska 1711 Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1&, PART I. Enter if!e chain ofevents- -diseases, injuries, or complications -that directly caused the death. DON enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT Aa9REYIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Left Cerebellar Infarct disease or condition resulting APPROXIMATE INTERVAL onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially lint conditions, if < b)Atherosc(eroSis any;, leading to the cause listed on line a onset to death Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or iniulythat injeiated onset to death the events remitting in death): LAST DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER Previous CVA, Mechanical Aortic Valve OR CORONER CONTACTED? ❑ YES: El NO 20. IF FEMALE' : : Not pregnant within past year P regnant at time of death ❑ Not p regnant , bu pregnant within 42 days of death ❑ - Not p regnant, butpregnant 43 da to 1 year before death ❑ unl;rwwn if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d ;'INJURYAT WORK? [YES DNO 231. DATE OP.DEATH (Mo., Day, Yr.) May 4, 2018 2311 PATE SIGNED (Mo., Day, Yr.) May 7, 2018 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Shawn S. Lawrence, MD 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO ® PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 23c. TIME OF DEATH 11:51 PM REGISTRAR'S siGNATU RE � - Could not be determined 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand island DAYS 5c. UNDER 1 DAY 9e. APT. NO. 2. SEX Male HOURS 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 2113.1F TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger Pedestrian Other (Specify) MINS. 24a,DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 3. DATE OF DEATH (Mo., Day, Yr.) May 4, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) March 6, 1949 9g. INSIDE CITY LIMITS ® YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE.CAUSE OFDEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY - home, farm, street, factory, office building, construction site, etc. (Specify) 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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 ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (INO., Day, Yr,) May 15, 2018