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<br />140'„ :•.3' • STATE OF .NEBRASKA
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<br />WHEN '< THIS I' 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
<br />i 4T�O, j DANCE
<br />LINCOLN,N199EBRASKA
<br />m
<br />m
<br />.0
<br />FOR VITAL RECORDS
<br />RUSSELL FOSLER
<br />2 O OR " �. ASSISSTATETANT DEPARTM NTF HEALTHR
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH -
<br />1. DECEDENTS -NAME `(First, Middle, Last, Suffix)
<br />Lloyd Lavem Miller
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 30, 2019
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-42-3455
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />8b. FACILITY -NAME (If net Institution, give street and number)
<br />CHI Health St, Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />] ER/Outpatlent
<br />O Dm
<br />DAYS
<br />HOURS
<br />MINS.
<br />IL DATE OF BIRTH (M
<br />,Day,Yt)
<br />February 18, 1937'
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<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 />2 Via Como
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g:`INSIDE CM UNITS:
<br />® YES ❑ NO
<br />10a. 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 />Elaine Marie Piontkowski
<br />Er : 11. FATER'S•NAME (First, Middle, Last, Suffix)
<br />. Harry John Miller
<br />s
<br />m
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unkl No
<br />16. METHOD OF DISPOSITION
<br />❑'Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑.Removal ;❑ Other (Specify)
<br />I< 12. MOTHER'S -NAME (First, Middle,
<br />JI Helen Louise Obermiller
<br />14a. INFORMANT -NAME
<br />Elaine Marie Miller
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Sb. LICENSE NO.
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />16c. DATE (Mo.. Day, Yr)
<br />September 3, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska'
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />3
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<br />10
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<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />O. PART f. Enter the chain ofev nts- -diseases, injuries, or complications -that directly caused the death, DO NOT enter tenfdnal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABSREYIATE. Enter only one cause oh a hop. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />m death)
<br />Sequentially list oonditions, H
<br />any, ieadina to the cause listed:.
<br />on tinea.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />a) Severe Hypoxic Encephalopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />APPROXIMATE IIITERVA
<br />onset to death
<br />1 Day
<br />Onset to ties
<br />onset to death
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART L
<br />Ischemic Heart Disease, Renal Insufficiency
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />D Not puegnam, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant wlthIRlhe past year
<br />22d. INJURY AT WORK?
<br />b ❑ YE$ ❑ NO
<br />N
<br />N
<br />a
<br />M
<br />i=
<br />S
<br />C
<br />re
<br />5
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES ®ro
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site, etc (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION' OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />21P CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 30, 2019
<br />25b. DATE SIGNED (Mo., Day, Yr.)
<br />August 30 2019
<br />23c. TIME OF DEATH
<br />01:27 PM
<br />3d. To thethe best of my knowledge, death occurred at time, date and place
<br />and due to the cause(s) stated. (Signature and 71tle)
<br />William Landis, MD
<br />26.131D TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ®UNKNOWN
<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 />24e. On the basis of examination and/or Investigation, in my opinion death occurred time,at
<br />the date end place and due to the cause(s) stated. (Signature and TSM)
<br />26a. HAS ORGAN OR se ATION BEEN CONSIDERED?
<br />❑ YES
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 3
<br />28b. DATE FILED BY REGISTRAR
<br />September 10, 2019
<br />(Mo., Day, Yr.)'.
<br />
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