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A. .11. STATE OF NEBRASKA , DATE OF ISSUANCE 8/30/2017 LINCOLN, NEBRASKA 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Donald Phillip Carter 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wood River, Nebraska 7. SOCIAL SECURITY NUMBER 505 -52 -6417. 8b. FACILITY -NAME Meat Institution, give street and number) CHI; Health Nebraska Heart re • 8c. CITY OR TOWN OF DEATH (Include Zip Code) O - I < K 9a. RESIDENCE - STATE 1 • Nebraska • 9d. STREET AND NUMBER 210 West 12th St. Lincoln 68526 10a, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married E j Married, but separated' 'CI Widowed ❑ Divorced ❑ Unknown . FATHER'S -NAME (Fret, Middle, Last, Suffix) John James Carter Jr g 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Yes; No, 01' Unk.) NO .8 15. METHOD OF DISPOSITION t- a ❑ Burial ❑ Donation IK] Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 2 7a. FUNERAL HOME NAME; AND MA LING ADDRESS (Street, City or Town, St Aofei funeral Home, 1123 W. 2nd. Grand Island. Nebraska IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiogenic Shock disease or condition resulting 'n death) DUE TO, OR AS A CONSEQUENCE OF: S equenglaly list conrhhons,if b) Myocardial Infarction a ny, leading tO the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (diseasenrinjury ttatinitiated ::; the events resulting ; n death) I.AST 2I) IF FEMALE: ❑ . Not pregnant Within pier year death ❑ Nat pregnant, pregnant within ❑ Pregnant at time o 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death Unknown n pregnantSMhinthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) -J U, z 2 0 14 j INJURY AT YES O RK? NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. WHEN THIS " COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE iA 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 REGISTRAR:3 SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 201804326 5a. AGE - Last Birthday (Yrs.} 76 !< 14a. INFORMANT -NAME Gwendolyn Janice Carter 16d. CEMETERY, CREMATORY OR OTHER LOCATION BML Cremation Service DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 2e. DESCRIBE HOW INJURY OCCURRED 23a. DATE OF DEATH (Mo., Day, Yr.) September 21, 2016 230 DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 23 2016 03:08 PM 3d. To the best of my knowledge, death occurred at the time, date and place a,•0 dne t• the sause(s) stated. (Signature and Title) Anul Jain, MD:;: CITY/TOWN OPER Cop 201706121 STANLEY S. ASS S ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES .7. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA ' Sc. CITY OR TOWN Wood River 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gwendolyn Janice Shiers 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Gladys Deenier DAYS CAUSE OF DEATH (See instructions and examples) . PART I. Enter the Chain of 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 0110 cause erl a line. Add additional lines if necessary. 18. PART I1. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined ❑ Pedestrian 0 Other (Specify) 25. PIO TOBACCO USE CONTRIBUTE TO THE DEATH? ' 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ Q NO U PROBABLY ® UNKNOWN ® YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Anuj Jain, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 9e. APT. NO. 2. SEX Male OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) HOURS 8d. COUNTY OF DEATH Lancaster 16b, LICENSE NO. CITY / TOWN Lincoln 5c. UNDER 1 DAY STATE MINS. 9f. ZIP CODE 68883 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) September 21, 2016 6. DATE OF BIRTH (Mo., :Day, Yr.) June 4, 1940 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) September 23, 2016 STATE Nebraska ?' 17b. Zip Code 68801 APPROXIMATE onset to death 3 Days onset t0 deo 3 Days onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator ❑ YES I1 NO ❑ Passenger ❑ Hospice Facility 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF<bEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) NTERVA ZIP CODE z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH o U � la E w 2 O 24e. On the basis of examination and /or investigation, in my opinion death occurred at g 2 the time, date and place and due to the cause(s) stated. (Signature and Tide) 24d. TIME PRONOUNCED ?DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES j NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 26, 2016