|
u$ ; c ct(M aatp���y 3yr't1,A
<br />Aue'MA��%)eW1/gH9itt�1F@uSth
<br />yrs 'rr, g p� ;�
<br />ii MJ➢li}�l� UM1�N S�#y V;aiiios
<br />•
<br />�fi,$rov,�(>a'�aUB.t�.rul�ca.ti(a@a�,
<br />YPi
<br />A4AA:.r1tS1y(ESISI'AOR?.✓sG...rir44,WA4tx:�:„tg;44FestiitttI, : '04,15'4
<br />%STATE OFNEBRASKA
<br />ditiat
<br />..,
<br />4@�a@$ d`,stauaa,,r >.zaoo4typNtas a
<br />WHEN THIS COPY CARRIES THE RAISED SEAL ` OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />10/2112019
<br />LINCOLN, NEBRASKA
<br />2 019 0'7 5 2 7 ASSISTANT REGISTRARSTATE
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMSNT OP; HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Evan Eugene Miller
<br />2. SEX
<br />Male
<br />'3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 9, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Benedict, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-30-2002
<br />art. AGE -Last Birthday
<br />(era.)
<br />90
<br />Sb UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 10, .192$
<br />Sb. FACILITY NAME (If not Institution, give street and number)
<br />108 West 21st Street
<br />g
<br />If
<br />94. RESIDENCE -STATE
<br />e Nebraska
<br />"-9d. STREET AND NUMBER
<br />108 West21st Street
<br />A
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />. CITY OR TOWN
<br />Grand Isla -(d'
<br />OTHER ❑ Nursing Home/LTC
<br />J] Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY UNITS'
<br />1 YES ❑ NO
<br />100. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />© Married, Out Separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Evan Edgar Miller
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Phyllis Ruth S(ogren
<br />} 12. MOTHER'S -NAME (First, Middle,
<br />Vera Mae Robertson
<br />Malden Surname)
<br />12. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME
<br />(Yee No, or Unk.) Yes 05/31/1951-06/01/1953 Phyllis Ruth Miller
<br />16. METHOD OF DISPOSITION 18a. EMBALMER -SIGNATURE
<br />Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Daniel D Naranio
<br />lSb.LICENSE NO.
<br />1071
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day,` Yr.)
<br />October 14, 2019
<br />1ed. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Greenwood Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY I TOWN
<br />York
<br />STATE
<br />Nebraska
<br />17b. Zip Cods
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PAR? I. Enter the Chain or event- diseases, injuries, or complications -that directly caused the. death. DO NOT enter anMtwt events such as cardiac arrest,
<br />respiratory Wilt. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ane cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />aiMEDIATE CAUSE((Final a) Chronic Systolic Congestive Heart Failure
<br />disease or condition resulting
<br />death)
<br />SequMRWM INt conditions, if
<br />any, k idln9 to the. Cause ward
<br />online •
<br />Enter the UNDERLYING CAUSE
<br />(dhMsi or ldplry tiler Initiated
<br />the events resuili M death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Ischemic Cardiomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Coronary Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Months
<br />onset to death
<br />Months
<br />onset to death
<br />Years
<br />19. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlons contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />Chronic Kidney Disease, Mild Cognitive Impairment OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20.1F FEMALE:
<br />0 Not pregnant within pest year
<br />0 Pregnant at time or death
<br />0 Not pregnant; but pregnant within 42 days or death
<br />0
<br />Not pregnant, bra plegn ni 41 days a 1 year before death
<br />❑ thilulewn N pt4ytagt withi in. past yar
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY
<br />32d. INJURY AT WORK?
<br />jYES NO
<br />21b.1F TRANSPORTATION INJURY
<br />0 Dttverlopereter
<br />0 Passenger
<br />0 Pedestrian
<br />Other MP ecihl
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />236. DATE OF DEATH (Mo., Day, Yr.)
<br />October 9, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 13 2019
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:20 PM
<br />34. To the test of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />jay C. Anderson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24*. DATE' SIGNED (Mo., Day, Yr.)
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and duo to the cause(s) stated. (Signature and Tale)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED? <'
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 16, 2019
<br />
|