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1ittdinflAllgematiVA @tett_ . s:.'tii'•< STATE OF NEBRASKA ti x<lkttiyiylaxtyt `l Wt�s.CYs's`- WHEN THIS COPY CARRIES THE RAISED SEAL OF 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 2/4/2022 LINCOLN, NEBRASKA 20 22.01087 , met. 4444, SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 19050 di E d 6 .�1 9 ro 0 0 0 u 4t E E 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Terry Glenn Muir 2. SEX Male 3. DATE OF DEATH (Mb., Day, Yr.): December 25, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Phillipsburg, Kansas 7. SOCIAL, SECURITY NUMBER 606-66-5932 8a. AGE - Last Birthday (Yrs.) 8b. FACILITY -NAME Of not Institution, give street and number) CHJ Health St, Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 71 6b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) August 12, 1950 OTHER 0 Nursing Home/LTC ❑ Decedent's Home o Other (Specify) I8d. COUNTY OF DEATH Hall 9d. STREET AND NUMBER: 312 Ca ntanChe Avenue Be. APT. NO. 9f. ZIP CODE 68803 90. INSIDE.CITY LIMITS' ® YES [ ..NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Rita Havel 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lonnie Muir 112. MOTHER'S -NAME (First, Middle, Gertrude Fisher Maiden Surname) 13. EVER IN U.S ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14e, INFORMANT -NAME Rita Muir 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION lE Burial ❑ Donation ❑;Cremation; ❑ Entombment ❑`Removal ❑ Other (Specify) 18a. EMBALMER -SIGNATURE Brandon S Bachle 16b. LICENSE NO. 1537 16c. DATE (Mo., Day, Yr.) December 29, 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska 17a. FUNERAL, HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 1713. Zip Cods 68801, CAUSE OF DEATH (See instructions and examples) la. PART I. Enter the chain of events- -disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAM (Mat < a) Pulseless electrical activity disease or condition resulting I' In death) Sequentially list conditions, If any, leading to the :cause ,:listed on Tina a. DUE TO, OR AS A CONSEQUENCE OF: b) myocarditis DUE TO, OR AS A CONSEQUENCE OF: Enterthe UNDERLYING CAUSE c) (disease or injury that initiated APPROXIMATE INTERVAL onset to death> Minutes onset to death Days onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART it. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. diabetes type 2, hypertension, hyperlipidemia, obesity, hypothyroidism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ®NO .20. IF FEMALE: ❑ Not pregnant within past year © Pregnant intim, of deatn 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown H pregnant within the past year 22a. DATE OF INJURY (Mo. Day, Yr.) 22d. INJURY AT WORK? ❑ YES „❑ NO 21a. MANNER OF DEATH Ea Natural 0 Homicide ❑ Accident 0 Pending Investigation 0 Suicide ❑ Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)' 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) December 25, 2021 CITY/TOWN' 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH February 3. 2022 10:19 AM tad, Tothe beat of my knowledge, death occurred at the time, date and place and Owe to the cause(s) staled. (Signature and Title) Jay C. Anderson, MD 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES NO O PROBABLY 0 UNKNOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 240. On the basis of examination and/or Investigation, in my opinion death occurred: at the time, date and place and due to the cause(s) stated (Signature and TRIO) _. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? OYES 1 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO 0 YES 0 tF 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE Qaaji t 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 3, 2022 CD CA) N, ,