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slIlli,.18dfi(aoa.A$�y�dl,ttdyll��il�uerlat��,i�iil�r�tiii�R%�Itoaa�i)$��II,yJ,1�tfErll�s/�°9� .euaai))Ya��(1i)(ihD irr 0.a *rest9tYYYalflaa :3\k 101111(0 3yi rlt4YriiJ�))1'�1/i( ((!(int,!` rlan gtr✓iUYYyI'B11aax3? }xrrrgm„� i_.�_. 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 2/24/2020 LINCOLN, NEBRASKA 202103336 rl7#1.ttr SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 02182 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Charles Lloyd Perkins 2. SEX Male 3. DATE OF DEATH IMO., Dsyy February 20.2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Stromsburg, Nebraska 7. SOCIAL SECURITY NUMBER 507-52-5423 6a. AGE - Last Birthday (Yrs.) 75 8b. FACILITY -NAME (If not Institution, give street and number) 2, 3023 Brentwood Place 11, 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68801 i 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER:: 3023 Brentwood Place 9b. COUNTY Hall 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 86. PLACE QF DEATH HOSPITAL 0 Inpatient ER/Ou patient ❑ DOA 9c. CITY OR TOWN Grand Island HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr) May 17, 1944. OTHER 0 Nursing Home/LTC Decedent's Home 0 Other (Specify) I8d. COUNTY OF DEATH Hall ❑ Hospice Fecal iy• 9e. APT. NO. 8f. ZIP CODE 68801 9g, INSIDE CITY LIMITS YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married v 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, ' Middle, Last, Suffix) If wife, give maiden name Deana Joleen Macke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dale Perkins 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Marcella Burgess 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) Yes 02/24/1966-02/23/1968 14a. INFORMANT -NAME Deana Joleen Perkins 10. RELATIONSHIP TO DECEDENT Spouse 16. METHOD OF DISPOSITION 2 ❑ Buriat ❑ Donation ® Cremation ❑ Entombment ❑'RsmovaF ' ❑Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 21, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATICYN CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) g Ali Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 44 SF CAUSE OF DEATH (See instructions and examples) 17b. Zip Code 68801 18. PART I. Enter the chain of events- disuses, injuries, or complications that directly caused the death. DO NOT enter tannins, events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ono cause on ■ lime. Add additional ,Ines 11 necessary. IMMEDIATE CAUSE: a) Chronic Systolic Heart Failure IMMEDIATE CAUSE . (Final diseate m cendhlpn r*dul*(ns £ In death/ Sequentially list conditions, it any, Iseding 101)45 Isuse 6.4.4 on line a. DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Obstructive Pulmonary Disease APPROXIMATE INTERVAL onset to death, #Ears onset to death Years DUE TO, OR AS A CONSEQUENCE OF: 5 Enter the UNDERLYINGCAtIBE c) Coronary Heart Disease p (disease or injury that initiated • the events resulting In doth) LAST onset to death Years DUE TO, OR AS A CONSEQUENCE OF: d)Physical Deconditioning onset to death Months 5 18. PART I1. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Had Left Ventricular Assist Device. Declined Clinically And Transitioned To Hospice And Passed Away m EO. IF FEMALE: ❑ Not pregnant admin past vier ❑ Pregnant at time of Wath ❑ Not pregnant, but pregnant within 42 days of dura m Not pregnant, but pregnant 43 days to 1 year before death 19. WAS MEDICAiEXAMINER OR CORONER CONTACTED? ❑ YES ® NO S C 0 Unknown it pregnant within the past year 21a. MANNER QF DEATH ® Natural ❑ Homklde ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY Dnver/Operetor Passenger 0 Pedestrian ❑ Other (Specify) 21e. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 122a. DATE OF'INJURY (Mo.,'Day , Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) E 22d. INJURY AT WORK? g ❑ YES❑ No, 22e. DESCRIBE HOW INJURY OCCURRED 2 041 21. LOCATION OF INJURY';' STREET & NUMBER, APT.NO. CITY/TOWN 0. 23a. DATE OF' DEATH (Mo., Day, Yr.) February 20, 2020 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH February 20. 2020 07:32 AM Id Toth* bast of my knowledge, dune occurred at me time, date and pea and. due to thin/tussle) stated. (Signature and This) Michael A. Donner, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP.CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 20. CA the beets of examination and/or investigation, M my opinion death occurred al Hp Mtn, date and place and due to ten mammals) stated. (Signature and 'Me) 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? GRI YES 0 NO 0 PROBABLY 0 UNKNOWN 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Il NO 127. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 26b. WAS CONSENT GRANTED? Not Applicable If 2651s NO 0 YES : Q NO: 28a. REGISTRAR'S SIGNATURE( 8I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 21, 2020 i