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tstit ` €I a ; a„Spr loam .r Atiii311t 161*Lttit a lad qty okiiio.olg§ lix44. • f r,, at err •^ sz.. zit t � �+yi Millie i[ev t4MANasr sx _.. __ i A ` !.M%sw1 `, : '?tz v wo ,. Farmplart 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 4/14/2021 LINCOLN, NEBRASKA 7 t't e' a_ )s -.7(.;40144+ SARAH BOHNENKAMP ASSISTANT STATE REGIS DEPARTMENT OF HEALTH' AND HUMAN SERVICES j STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20210887/ Rkt 21 04659 Pursuant to section 30-2413, demands for notice Which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Carolyn Marie Anthony 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) April 4, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day. Yr,). Grand. Island, Nebraska (Yrs.) 73 MOS. DAYS HOURS MINS. August 19, :1947 T. SOCIAL SECURITY NUMBER 507-64-5876 8a. PLACE OF DEATH HOSPITAL Ig Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home ❑ DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code)8d. Grand Island' 68803 I COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9e. CITY OR TOWN Grand Island 94. STREET AND NUMBER . 1518 W 4th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g, INSIDE CITY LIMITS a YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jimmy Jay Anthony 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Owen McCown Helen Buck 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jimmy Jay Anthony 14b. RELATIONSHIP TO DECEDENT,? Spouse 15. METHOD ❑ OF DISPOSITION Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 6, 2021 ® ❑ Cremation 0 Entombment Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME All Faiths Funeral NAME AND MA LING ADDRESS (Street, City or Town, State) Horne, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) '15. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, IMMEDIATE CAUSE disease or condition or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: (eine a) Systolic Heart Failure resulting onset to death Years In deem Sequentially list conditions, any, leading to the cause DUE TO, OR AS A CONSEQUENCE OF: if b) Cardiac Arrest listed onset to death Minutes on rinse. Enter the UNDERLYING (dl or injury that DUE TO, OR AS A CONSEQUENCE OF: CAUSE c) initiated' onset tot#aath the events resulting LAST In death) DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II, OTHER Hypertension SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ® Not pregnant within pari year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO ❑ Not pregnant, but pregnant within 42 days of deathsuicide ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ ❑ Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES El NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be-.compieted by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) April 4, 2021 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 6, 2021= 23c. TIME OF DEATH 01:20 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best and due to Susan M. Only knowledge, death occurred at the time, date and place the cause(s) stated. (Signature and Title) Newman, MD 34e. On the basis of examination and/or investiga ion, In my opinion death atou red at the time, date and place and due to the cause(s) stated. (Signature and Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 131 NO .PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 5 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 717. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Susan M. Newman, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 r 28a. REGISTRAR'S SIGNATUREa�� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 12, 2021