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<br />STATE OF NEBRASKA 7
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<br />THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA; IT CERTIFIES THE DOCUMENT BELOW T
<br />BEA TRUE COPY OF ME` ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />j* ATE ISSUANCE
<br />2/25/20
<br />LINCOLN, NEBRASKA
<br />202203822
<br />,6t4
<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 DECEDENTS:NAME (Ffust, Middle, Last, Suffix)
<br />Harold BuQetTe. Carmichael Jr
<br />4. CITY' AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand;:Island, Nebraska
<br />T SOCIAL SEcuR nY NUMBER,;
<br />505444376'
<br />8a. AGE - Last B)rthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />4246 Brandin i iron Court
<br />8c ci1 Y OR TOWN OF DEATH (Include Zip Code)
<br />Grand Islam 68801
<br />9e. RESIDENCE -STA
<br />Nebraska
<br />9d STREET AND NUMBER
<br />4246 Brandin Iron Court;.
<br />90a. MARrrAL STJiTUSAT TIME OF DEATRIZI Married 0 Never Married
<br />0 MauTied, but separated 0 Widowed 0 Divorced 0 Unknown
<br />8b. COUNTY
<br />Hall
<br />54. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />69
<br />MOS.
<br />DAYS
<br />Sa, PLAC(x9 DEATH
<br />HOSPITAL ❑Inpatient
<br />In ER/Outpatient
<br />❑ DOA
<br />11 FA'f#i8-NAME.; (First, , A
<br />H arold Carrnic Dot
<br />t, Suffix)
<br />13. EVER IN U S.. ARMEDFORCES? Give rates of service H Yes.
<br />(Yes,; No, or Unk.) NO
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH jMo i.yr
<br />January 21,'202Z
<br />8. DATE OF BIRTH:IMtt., Day, Yr::.)
<br />October 17, .1962::.
<br />OTHER ❑ Nursing Home/LTC:
<br />II Decedent's Hary
<br />0 Other(Specifyj
<br />8d. COUNTY OF DEATH
<br />Mt. APT. NO.
<br />8f. ZIP CODE
<br />68801
<br />1011 NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, givemel
<br />Kathy Callan
<br />14a. INFORMANT -NAME
<br />Kathy Carmichael
<br />1,2 MOTHERS-NANE (First,
<br />MaT lie Kilner
<br />Middle , Mi
<br />T ..
<br />1111. cnYt ours ;
<br />_
<br />iib. RELAT(ONS'rO DECEDENT
<br />Spouse
<br />1.5 METMOD OF DISPOSITION
<br />❑ eurlai Q Dplratiora
<br />Cremation Q Entombinertt.
<br />❑rtemtnoN ❑OthertSPeY1
<br />18a, EMBALMER SIGNATURE
<br />Not Embalmed
<br />led. CEMETERY, CREMATORY OR OTHEI
<br />Kremer Crematory LLC
<br />LOCATION:;
<br />1Ta. FUNERAL HONE NAMME,AND MAILING ADDRESS (Street, City or Town, State).:,:::::„
<br />Kremer Funeral Home, Inc., 6302 Maple Street, Omaha, Nebraska
<br />18b. LICENSE NO.
<br />18e. DATE (Mo.,
<br />Januar 20,2022
<br />CAUSE OF DEATH (See instructions "and examples)
<br />IT9t z . cede
<br />IL PART I, Enter the chain of events- -diseases, Injuries, or compikatlone<hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />resplraicly arrest, or. ventncularflbdNaatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines It necessary.
<br />IMMEDIATE CAUSE:
<br />a)Alzheimer Dementia with behavioral disturbance
<br />a'AME(llATE CAiffigipmet..
<br />. tllsesel or eoaditica rosaiHi
<br />In death)
<br />sequentially get conditions, If
<br />any, reeding to the cause Hated..
<br />0.11,105:
<br />this UNOIRI:kftitl #040E.
<br />(dbeaas ariniury iRath+itteted".
<br />DU
<br />b)
<br />TO, OR AS A CONSEQUENCE OF:
<br />•
<br />LI /0, OR AS A CONSEQUENCE OF:
<br />1 S. PAR T S: OTttER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting
<br />depression, constipation
<br />20.IF FEMALE
<br />❑ Nittptegnsntw(hMnpt
<br />❑ PaagnantAt thttit of dead,
<br />© Not.. ju grteM, relit pregnant ions
<br />0 Not pregnant, but pregnant 43
<br />Unknown ttpregnaa v2 ln.tt a put soar
<br />$ days of death
<br />to 1 year before death
<br />TEi
<br />iN)U
<br />(Mo Day'
<br />22d. INJURY AT WORK?
<br />[] S [l NO
<br />YE
<br />21a. MANNER OF DEATH
<br />®Natural ❑ Homicide
<br />❑ Accident ❑Pend)ng'Investigatio l
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22f. LOCATION OF':INJURY -STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo„ Day, Yr.)
<br />January 21, 2022
<br />in dee underlying cause given in PART I.
<br />21b..IF;TRANSPORTATION INJURY('
<br />E1DdvedOperator
<br />❑PIISAenger
<br />❑;PaWstdan'
<br />0 Other (Specify)
<br />19. WAS MED St, EXArdENER
<br />OR CORONERCt ACTED?
<br />❑Y sIPJ
<br />21c. WAS AN AUTOPSY::
<br />0 YES
<br />21d. WEREAuToPey FINDINGS AYAiLABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />TES D No
<br />22c.'PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo , Day, Yr.) 23c. TIME OF DEATH
<br />Ja�iItta Y 26 ':2022 03 00 PM
<br />Toretreatgins death otcurred at the time, date and place
<br />and dna WSW settings) stated. (Signature. and Title)
<br />Jay C. Anderson, MD
<br />DID vsecp,pstCONTRIBUTE TO TNE:DEATH?
<br />PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF
<br />ATH
<br />ZIP -CODE
<br />24d. TIME PRONOUNCED.DEAD
<br />24e.On the bsaii'of examination and/or investigation, In my opiniondeatb:ai.
<br />the ttnu, date and place and due to the cause(s) stated. (aignNan aid:;'
<br />28a. HAS ORGAN OR TISSUE! DONATION ;BEEN CONSIDERED?
<br />❑ YES idl NO •
<br />SIT. NAME, TITL4 AND tipDRESB OF CERTIFIER (Type or Print
<br />Jay:0: AndereDb. MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANT
<br />Not Applicable if 28a is NO
<br />YES:'
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />February 10, 2022 ...
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