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<br />STATE OF NEBRASKA
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<br />WHEN :.71.1. COPY CARIES THE RAISED SEAL OF STATE OF NEBRASKA; IT CERTIFIES THE DOCUMENT BELOW TO
<br />'BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HtIMAN'SERVICES, VtrTAL RECORDS OFFICE, WHICH IS' THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATB:.O.P:ISSUANCE
<br />....... ...:.... ....... .......
<br />2/412022
<br />COLN, NEBRAS
<br />20220506
<br />ekt/Lz/7
<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 />f :ECEDENTISAIAME (First
<br />Nri Glenn Muir'
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Suffix)
<br />Phillipsburg, Kansas
<br />CIAL SECURITY i
<br />6-5932
<br />UMBER
<br />6a.AGE - Lest Bledtday.
<br />etre.
<br />71
<br />8b. FACtLlTY-NAME (If not institution, give street and number)
<br />CHI; Health St. Francs
<br />8c. CITY CR.TIE:WN OF DEATH (Include Zip Code)
<br />Grand island 88803
<br />9e. RESIDENCE -STA'
<br />Nebraska
<br />9d.:STREET:ANfS NUdtaEi'l'
<br />312 Comanche Avenue
<br />9b. COUNTY
<br />Hall
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a, ALAGE OF DEATH
<br />HOSPITAL, ®Iafpatient
<br />❑ ER/Outpatient
<br />[] DOA
<br />10a. MARITAL STATUS ATTIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />�11 FATHERS NAME (Fttd
<br />Donnie 11Auir
<br />Middle,
<br />Last,
<br />Suffix)
<br />. s 13. EVER IN U.S ARMED FORCES? Give dates of service ((Yes.
<br />g (Yes, No, or Unit.) No
<br />.16. METHOD
<br />METHOD OF DISPOSITION
<br />t,;tr)ai ❑Dttnation
<br />( rematieni OEnters
<br />Q Remove( '' ❑ oth®r (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 19050,
<br />3. DATE OF DEATH. t . G
<br />December 26;.2021
<br />6. DATE OF SIRTN'(Mo., Day,:Yt )
<br />August 12,.1.950:.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />as. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Ob. NAME OF SPOUSE (Mt, Middle, Last, Suffix) If wte, give maiden node
<br />Rita Havel
<br />1.
<br />12 MOTHER'S.NAME (First, Middle,
<br />Gertrude . Fisher
<br />14a. INFORMANT -NAME
<br />Rita Muir
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bechle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand island City Cemetery
<br />17a. FUNERAL,HOME NAME AND MAIUNG ADDRESS (Street, City or Town,:State)
<br />Apfel Funeral Hi,rn ; 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH(See instru
<br />16b. LICENSE NO.
<br />1537
<br />CITY ITOWN
<br />Grand Island
<br />ont and examples)
<br />'
<br />14b. RELATIONSHIP TO DECEDENT;
<br />Wife
<br />18c. DATE (Mo Dsy, Yr )
<br />December 2C2021:$
<br />18. PART I. Enter the chain of U 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 ABBREVfATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />ttetsuw*.aausietnnt a) Pulseless electrical activity
<br />mow. or enclelott resiittiney.
<br />In award,
<br />Setpnsntldiy gat condmons,
<br />any, feadtIts to the.aause lie
<br />sereface:deitiaitOtiNcItedeff.
<br />(dlsease.ur Injury tat Iniaatad
<br />the events resuMng in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />4}myocarditis
<br />DUE TO, OR A CONSEQUENCE OF:
<br />c)
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />1}
<br />STATE
<br />Nebraska
<br />74 ZIp Qode ::
<br />
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