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<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 />4/21/2020
<br />LINCOLN, NEBRASKA
<br />202002988
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Ronald Wesley Carlson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cedar Rapids, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-42-6804
<br />8b. FACILITY -NAME. (if not Institution, give street and number)
<br />tit
<br />E CHI Health St. Francis
<br />v
<br />v
<br />8
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4166 Mason Avenue
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />,Yrs.)
<br />84
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. I DAYS
<br />HOURS MINS.
<br />20 04932
<br />3. DATE OF DEATH (M0.,.D#y, Yr.)
<br />April 13, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 30, 1935.
<br />1aa. :MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />led. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Betty Lee Ostrander
<br />11. FATHER'S -NAME (First,
<br />Wesley Carlson
<br />Middle, Last, Suffix)
<br />112. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Ruby Hale
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 10/05/1956-10/03/1958
<br />14a. INFORMANT -NAME
<br />Betty Lee Carlson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Ea Bunal ❑Donation
<br />❑ Cremation ❑Entombment
<br />❑ Removal ' ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />April 18, 2020
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Main Cemetery
<br />CITY / TOWN
<br />Belgrade
<br />STATE
<br />Nebraska
<br />170. FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801;,
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART I. Enter the chain of events- 41seases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Arrest
<br />IMMEDIATE CAUSE (Final
<br />tlfaease oreomdaion resulthtg'
<br />in death)
<br />Sequentially list conditiore, if
<br />any, leading to the cause listed
<br />on linea,._. _.
<br />Enter tin LINO*RLYING CAUSE
<br />(disease or trQurylhst"Witted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cardiac Arrythmia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Day
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _.. d)
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />O. IF FEMALE;
<br />Not Freimant within past year
<br />N ❑ Pinner* name of death
<br />❑;Notpregn4nt, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />C
<br />©;. Unknown qpmtin
<br />gnant within e put year
<br />22a.DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />V
<br />I'f
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑.Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />O YES 14 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, Mc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22fLOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN
<br />c
<br />0
<br />Sa
<br />A g
<br />E -t
<br />0.
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />April 13, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 16. 2020 08:41 PM
<br />3d TO ane beat of my knowledge, death occurred at the tkns, date and place
<br />Add duitto Me ausers) stated. (Signature end Title)
<br />Isaac J. Berg, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24a. On tin basis of examination and/or investigation, in my opinion death occurred et
<br />she time, date and place and due to the causer') stated. (Signature and Titre)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES IS] NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island,Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />la✓24-11 Bow n e�z, 1z,ry
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ` ❑ YES © NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 17, 2020
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