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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 />12/21/2020
<br />LINCOLN, NEBRASKA
<br />2 0 21 0 5 8• SSA/RAH BOHNEN KAMP t,
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />20 18114
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased am filed with the county court in the county where the decadent resided at the time of death.
<br />1. DECEDENT'$ -NAME (First, Middle, Last, Suffix)
<br />Charles Anthony Scott
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo„ Day,Yr.)
<br />December 9, 2020
<br />4. CITYANDSTATE. OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ba. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day,Yr.)
<br />Greeley, Nebraska
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />July 6, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-0200
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />#17 Kuester Lake
<br />0 ER/Outpatient ®Decedent's Home
<br />0 DOA ❑ Other (Specify)
<br />8c. CITY OR TQWN
<br />Grand Island
<br />OF DEATH (Include Zip Code)
<br />68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d, STREET AND NUMBER
<br />#17 Kuester Lake
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />0 YES E NO
<br />105. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Angela Zwiener
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Anthony John Scott
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Pearl Elizabeth Rease
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Angela Scott
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />18b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />December 17,2020
<br />Cremation ❑Entombment
<br />Removal " 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as Cardiae arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUSE(Final a) Respiratory Failure
<br />disease of condition resulting`
<br />onset to death
<br />Immediate
<br />in death) DUE TO, OR ASA CONSEQUENCE OF:
<br />Sequentially list conditions, If b)Dementia
<br />any, leading to the cause: listed
<br />on Dm a.
<br />onset to death
<br />Years
<br />_.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Prostate Cancer
<br />(disease or injury that Inlisted
<br />onset to death
<br />Years
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)Malnutrition
<br />onset to death
<br />Weeks
<br />18. PART 11. DINER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Patient Declined Clinically And Transitioned To Hospice Care And Died At Home
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant al pmeof derail
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide .
<br />❑Accident 0 Pending Imastigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES l NO
<br />❑'Not pregnaM, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ unknown If pregnant within the past year
<br />suicide Could not ba determined
<br />0 ❑
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<br />22a. DATE OF INJURY (Mil., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES, ❑ N0
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 9, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />a COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />0
<br />I>•
<br />a
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Decernber 14, 2020
<br />23c. TIME OF DEATH
<br />11:03 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0
<br />e
<br />~ :
<br />O
<br />2�d. Tothe fleet of my knowledge, death occurred at me time, date and place
<br />add dw tothe causes) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />240.On the basis of examination and/or Investigation, in my opinion death assorted at
<br />the time, date and place and due to the cause(s) stated. (Signature end TNIe)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 'E NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES RI NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES 0
<br />2T NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE� - A /1
<br />�! r�d'11-" e/1? 4 -Pt _f -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 16, 2020
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