|
tELnA11111i111W, r,4Ji1vok4r,,,,pAINliAAg1%G%.CGI;
<br />Cr:..9JJr�` _I141I1111111`� '
<br />11111111111f ! ir ,1•••:?
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, ' 1T
<br />CERTIFIES THE LtipCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RE
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE O .ISSUANCE
<br />7/8/2021
<br />LINCOLN, NEBRASKA
<br />Ark,'
<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 :DEGEgENT$ NAME :(First, Middle, Last, Suffix)
<br />Chdstian Durno Terman
<br />4 CITY ANDS ATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Sidney, Nebraska
<br />!WAGE . LaetBlrthday
<br />(Yrs.)
<br />?..SOCIAt SECURITYNUMBER
<br />T28r03-Q9$S
<br />8b, FAOILI 4,,*AME#if not Institution give •street and number)
<br />Grand Island Country House, L.L.C.
<br />8cCtTY ORTGWNYF DEATH (ktdude 2lp Code)
<br />Grand Isnd 68803
<br />9a` RESIDENCE -STATE
<br />GG Nebraska
<br />&TREETAND NUMBER
<br />31 E, Phoenix Ave.
<br />84.
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />2107850
<br />S DATE OF DEATHMIc rDa 'Yr.)
<br />June 10, 2021
<br />cDATE OF BIRTH (Ms., Oay yci
<br />November 13, 1936
<br />8a. Pta4CE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC El Hospice Facility
<br />0 ERIOutpatient 0 Decedent's Home
<br />0 DOA ®Other (SPS )ASSISTED
<br />18d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island`
<br />Be. APT. NO.
<br />9f. ZIP CODE 5Ig..INSIffE PTV LIMITS
<br />68801 Y"'
<br />Q.` rpq
<br />Suffix) If wife, give maiden naives
<br />16a'MARITAL 'STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Mewled, but separated ❑ Widowed , 0 Divorced 0 Unknown
<br />11 FATHER'S'NAME (first;
<br />Chris Ter#Yian
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Marjorie Rubottom
<br />112. MOTHER'S -NAME (First, Middle,
<br />Mildred Marjorie Nelson
<br />13. EVER !NUB. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />18 METHOD OF DISPOSITION
<br />Burial ::> . ❑ t Conation
<br />(] Crematian Q Entombment
<br />Rrmtoval [ tifarfer (Specify)
<br />14a. INFORMANT -NAME
<br />Marjorie Terman
<br />lea. EMBALMER -SIGNATURE
<br />Chris McCov
<br />Maiden Str
<br />16b. LICENSE NO.
<br />1191
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />D1`e( Funeral H'ot e, 1123 W.G2nd, Grand Island, Nebraska
<br />14b. RELATIONSHIP TO DECEDENT -'
<br />Spouse
<br />tad DATE (Mo, Day,
<br />June 26 2
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injures, or complicatfons4hat 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 addRional lines If necessary.
<br />IMMED ATE CAUSE:
<br />a)Respiratory Failure
<br />Nebraska
<br />1Tb ZPCodo
<br />68601:'
<br />pr eenddion resuttiela
<br />Sequentially list conditions, R
<br />any,; leading to;the Cause fisted
<br />orE:iioa a
<br />E rfet the 010a.t t.YI.I I:AiIsE
<br />Idtt ease or in)u/y:that initiated
<br />the events resulting in death)
<br />IAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Parkinson's Disease
<br />APPROX/EIATE INTERVAI.
<br />•
<br />�' ens¢ttode#1h,
<br />2 D61us
<br />ons to death
<br />16 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />meet 1E+ dee
<br />I onset to death
<br />18 PARTII 0T'liER S GN.lEICANTC0NDITIONS-Condlflons contributing to the death but not reSultIn():In the underlying cause given In PART L
<br />Patkinsons :Disease
<br />IF FEMALE .:
<br />Nat pregnant wtthi • pagf:year
<br />©. PrsgnaiN at':t&as Af tieatft
<br />0
<br />Not Pre
<br />:: Net pregnant, but pregnant within 42,days of death
<br />gnant, but Pregnant 43 days*, 1year before death
<br />0 unknown it:egteaitt with
<br />in the pant year
<br />GAN OF INJURY (Go-, Day, Yr.)
<br />21e. MANNER OF DEATH
<br />® Natural Q Hmniclda
<br />❑ Accident Q Handing
<br />0 Bulcide Envssdgadon
<br />❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />%19: WAS M D(CA1, k3IAMlNErR
<br />OR CORONER COttTAffi li'
<br />YES §il N0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑.I
<br />21d.21d.wiffiffiAUTOPSYRINONGSAAILABLE
<br />TO COMPLETE PLETE CAUSE OF DEATH?
<br />22c. PEACE OF INJURY -At home; farm, street, factory, office building, conearut
<br />22d. INJURY AT WORK?'
<br />O YES.:::.❑ NO.,
<br />22f`1 OCATION 0Fz.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET m NUMBER, APT.NO.
<br />DEATH (Mo., Day, Yr.)
<br />June 10, 2021
<br />DATE SIGNED (Mo., Day, Yr.)
<br />23a. DATE OF
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />23b.23c. TIME OF DEATH
<br />Jrne 18,,2021 03:00 PM
<br />Jd ro:tbe bast of illy knowledge; death oecutted gibe time, date and place
<br />and wok/ ill* ea ME)1 aid. (si@nature and Title) ,:
<br />2.5.ffiD.:TOBACCO,USECONTRIBUTE TO THE DEATH?
<br />.•:NAMffilTffiff ANDADDRESS OF CERTIFIEK (Type or Print
<br />-tat IlartiMID, 729.Noith Custer Avenue, PO Box 233LOrandisland,,Nebraska, 68803
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. Tom. D DEAD
<br />24e. On the basis of examination andfor bwestigatIon, in My OpIrdan 48881fLil
<br />ihe thne, date and place and due to the sauseptistated..(Signaturfifilid
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES NO
<br />2611 WAS CONSENT GRANTED? .
<br />Not Applicable If 26a Is NO
<br />28b. DATE FILED BY NerasiaaR agio., Day, Yr.)
<br />June 21, 2021
<br />
|