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r!()Zw a€issku$$?)I wj/�,ttvaatayttztt99RYirttt>a ,rte £IiSVJI)tr, y3351'AVCaxa �rtztii9y 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 11/16/2020 LINCOLN, NEBRASKA 202103302 �I rrf7Jre[•r SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 2015442 0 m E 2 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Donald Edwin Miller 2. SEX Male 3. DATE OF DEATH (Mo.,,Day, Yr.) r Novembe9, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Beaver Crossing, Nebraska 5a AGE - Last Birthday (Yrs.) 97 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) June 8, 1923 7. SOCIAL SECURITY NUMBER 506-22-6071 8b. FACILITY -NAME (If not Institution, give street and number) The Heritage at Sagewood 8a. PLACE OF DEATH HOSPITAL 0 Inpatient 0 ER/Outpatient ❑ DOA OTHER 0 Nursing Home/LTC 0 Decedent's Home Other (Specify/ASSISTED LIVING ❑ Hospice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island I8d. COUNTY OF DEATH Hall 9d. STREET AND NUMBER 1920 Sagewood Avenue De. APT. NO. 9f. ZIP CODE 68803 . INSIDE CITY0LIMITS IJ YES NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married 0 Married, but separated ® Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dorothy A Blackwell 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Malden Surname) Beryl Miller Ruth Larkin 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 02/19/1945-07/02/1946 14a. INFORMANT -NAME Allan Miller 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION Mr Burial ❑ Donation 0 Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) November 12, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Wood River Cemetery Wood River STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 13. PART I. Enter the chain of events- .diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular nbnitetion wi.hout showing the etiology. DO NOT ADOREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a)Acute On Chronic Respiratory Failure IMMEDIATE CAUSE (Final die ase er condaien resulting; In deaths Sequentially list conditions, if any, leading to the cause listed on line a Enter the UNDERLYING CAUSE (dbuss or Injury that initiated the events resulting In death) LAST APPROXIMATE INTERVAL onset to death Months DUE TO, OR AS A CONSEQUENCE OF: b)Congestive Heart Failure onset to death Years DUE TO, OR AS A CONSEQUENCE OF: C) Ischemic Heart Disease onset to death Decades DUE TO, OR AS A CONSEQUENCE OF: d) 18.;PARTII. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Copd, Afitt 20. IF FEMALE: 0 Not pregnant within haat year 0 Pregnant at tin* of death [3 Net pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ unknown tf pregnant within the past year 22a, DATE OF INJURY (MO;, Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 21a. MANNER OF DEATH Natural 0 Homicide ❑ Accident 0 Pending investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger ❑ Pedestrian ❑ Other (Specify) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Il NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, ere. (Sperry) 22e. DESCRIBE HOW INJURY OCCURRED 221, LOCATION OF INJURY STREET d NUMBER, APT.NO. 23a.DATE OF DEATH (Mo., Day, Yr.) November 9, 2020 23b. DATE SIGNED (Mo., Day, Yr.) November 9 202 a CITY/TOWN 23c. TIME OF DEATH 08:09 AM d. MAN 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? YES 0 NO 0 PROBABLY ® UNKNOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investiga ion, in my opinion death *attuned at the time, data and place and due to the causes) stated. (Signature alta Tale) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ; ®NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE L 3L '2 it BaA--ic.&-n 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES © 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 12, 2020