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STATE OF NEBRASKA ,''#'
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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,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/2/2021
<br />LINCOLN, NEBRASKA
<br />202202577
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<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last,
<br />Daniel Charles Burritt
<br />Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Shelby, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (mo., past, Yt.)
<br />July 30, 2021
<br />6. DATE OF BIRTH. Mo., DA Yr.)
<br />December 26, 1934
<br />7. SOCIAL SECURITY NUMBER
<br />505-34-1155
<br />8b. FACtLITY-NAME (Knot Institution, give street and number)
<br />CHI Health St, Francis
<br />8c. CITY QR TOWN OF DEATH (Include Zip Code)
<br />Grand Isla rid 68803
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC ' ❑ Hospice Facfifty
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d,::STR£ET AND NUMBER
<br />668 E, Ashton Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />8p INSIDE CITY LIMITED::
<br />® YES ❑ NQ
<br />10S;MASITAiiiiSTATIJS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />0 Married, but separated 0 Widowed ` 0 Divorced ❑ Unknown
<br />10b. NAME OF. SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Glenda May Bader
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />Monetha Wilson
<br />Earl Burritt
<br />Maiden Sumame)
<br />13. EVERIN U$ ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />Give dates of service if Yes.
<br />14a. INFORMANT -NAME
<br />Glenda May Burritt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />Cremation; ❑ Entombment
<br />❑ Removal : 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />August 2.:„2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL. HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths FuneraljHome, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />17b. Zip Code
<br />18. 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,
<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 />a)subdural hematoma
<br />IMMEDIATE CAUSE (Final
<br />die -ease of tonditkin resuhmg'.;
<br />In death}
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on l ne a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)fall in the home
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />• Enter the UNDERLYING" CAt/SE C)
<br />(disease or inju4 . that irsttated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />chronic anticoagulation ,atrial arrhythmia
<br />20. IF FE.MALE:,
<br />❑ Not ptggnantwithtn past year
<br />© ;Pregnant ai time of death
<br />❑ ',i•Ipt pregnant; but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />O Natural 0 Homicide
<br />® Accident ❑ Pending Investigation
<br />O Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onsetfo death.
<br />5 Days
<br />onset to death
<br />5 Days
<br />onset to death
<br />19. WAS MEDICAL EXAMINER?
<br />OR CORONER CONTACTED?
<br />❑ YES I NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY::FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ._
<br />22a.'.DATE OF INJURY (Mo., Day, Yr.)
<br />Unknown
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,etc. (Specify)
<br />Home
<br />22d. INJURY At WORK?
<br />0 YES ®NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ground level fall
<br />22f. LOCATION OF INJURY' STREET & NUMBER, APT.NO.
<br />688 East Ashton Ave, Grand Island
<br />CITY/TOWN
<br />STATE
<br />Nebraska
<br />IP:GQDE
<br />68$01
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 30, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 26,>2021
<br />23c. TIME OF DEATH
<br />01:30 AM
<br />3d. TO the bast dray knowledge, death occurred at the time, date and place
<br />end due to the causes) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH''
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination andlor investigation, in my opinion death oocumetl aE
<br />the time, date and place and due to the cause(s) stated. (Signature and T 4errIe >,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES El ND ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />27. NAME, 71TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Grouch, 00, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 26, 2021
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