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<br />Jcatt 4u01l!i
<br /><__ STATE OF NEBRASKA
<br />IJddlf r v/&YI'111111ddlrr 5/r4u`Ildda :. r/td111t11f(1ldt .; frrrryr, 11\
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE 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 />DAI•E : ISSUANCE
<br />7/1;112022
<br />LINCOLN, NEBRASKA
<br />20220632
<br />.. e4, %4°.i7 iai .id.dn.I'.si r/d.
<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 DEATILI •
<br />1. pWDENr$.NAME =First, Middle, Last, Suffix)
<br />JarTles t3l(ro(d Langford
<br />STATE Oft TERRITORI OR FOREIGN COUNTRY OF BIRTH
<br />Norttf Platte, Nebraska;
<br />7 SOCIAL.$ECURITYNUM9ER
<br />5..06.-58-5334
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />74
<br />ro
<br />8b. FACILITY -NAME (1f not Institution, give street and number)
<br />U:NMC
<br />8c CITY OR
<br />TOW
<br />.N
<br />a:: 6819(C
<br />ow. RESIDENCE -STATE
<br />Nebraska..
<br />9d:.sTREET ANo:NUMeER
<br />1323 Redd Road
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a.;PLACE OF DEATH
<br />HOSPITAL, ®knpatient
<br />❑ ER/Ou patient
<br />DOA
<br />ARITAL.STATUS AT'Ti,
<br />9b. COUNTY
<br />Hall
<br />3EATH El Married 0 Never Married
<br />art)ed, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 Atigri.S IAME (F1tSt, Mlddie, Last, Suffix)
<br />!Raymond,. Langford
<br />13. EVER IN US, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. M;ETN00 OF DISPOSITION
<br />Burta( ❑ Donsilon
<br />it renisuon': D Entorr bntcnt
<br />O'Rertrovai. ❑ether(Specjfy)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MIN
<br />3. DATE OF DEATH (Mo., Day
<br />July 4, 202
<br />8. DATE OF BIRTH '('Mo.;.Day;`W.)'
<br />January 17,
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />8e. APT. NO.
<br />1Ob. NAME OF SPOUSE (First, Middle, Last,
<br />Mary Grieb
<br />14a. INFORMANT -NAME
<br />Mary Langford
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE
<br />68803
<br />Fud(lity ::::
<br />x) If wife, give m
<br />Sg. IN&fDEjril'#'Y3 i4A1T3
<br />®:ass ❑ NQ
<br />12. MOTHERS -NAME (First,
<br />Jeanne Burke
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Autumn Hills Cremation Services
<br />t7a FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Cerpenter;Mem rial Chapel 1616 West B Street, North Platte,: Nebraska for
<br />Jghj GljtntlelfiaraMortuaries; 1010 N. 72nd. Omaha, Nebr lea
<br />CAUSE OF DEA'. • (See instructions and examples)
<br />18b. LICENSE NO.
<br />Middle,'' Maiden Su
<br />CITY / TOWN
<br />Omaha
<br />111P Enter the chain Of 858018. •di*eaSes, injuries, or complications Shat 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 Inc.lAdd additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEbIATECAUBEIF.._
<br />drsaase or condtleI reseonng;
<br />in death)
<br />to 8equenhaiiy 1111 conditions, If
<br />et arty ;laadlrtj#.to the neuas rrstad
<br />orrllne ...
<br />Entpljsa tNdbEALYiNBCAusE
<br />(disease or injorythat incited.
<br />the events resui6ng In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Neutropenic Fever
<br />DUE TQ, OR A8 A CONSEQUENCE OF:
<br />c)Aoute myeloblastic leukemia
<br />LAST DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART it DTI ER SONIFt.
<br />Congestive heart failure
<br />ONDITIONS-Conditions contributing to the death t
<br />14b. RELA fIO
<br />SOOtise
<br />lac. DAT
<br />JUIy a,
<br />not resulting; In the underlying cause given in PART L
<br />1-
<br />2D IF::FEMALE;
<br />lyot lh agnant.s8e110 past j ear
<br />0 Preg000t ablate of deadl
<br />D NOTaregnalibut pregnant within 42 days of death
<br />❑ Not Pregnant, but pregnant 49 days td l year before death
<br />4fnkn4twl If Pragnadt tvltl i l the psst:year
<br />2a
<br />#JATaOFIPIJURYtMo D
<br />22d. INJURY AT WORK?
<br />QYES..DNO .:
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide •
<br />O AccldeM ❑•Papong Investlgetjo
<br />Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />JURY::: STREET& NUMBER, APT.NO.
<br />23a. DATE OF DEATai (Mo ,, Bay, Yr.)
<br />July 4,2022
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Dnver/Operator
<br />❑ Paahenger
<br />0 Pedestrian
<br />❑ Other(Specify)
<br />SHIP TO DECEDENT":
<br />A
<br />Nebraska
<br />1xh. !1lriiCade>:.
<br />t;�1IAA
<br />ATE INTERVA
<br />ortsettodeeth>
<br />Davis
<br />onset Nr death
<br />Day
<br />onset to death
<br />19. WAS MEDIC (n:EXANNNE ,
<br />OR CO RAINER CONT'ACTSD?.
<br />❑ YF.a IJ NO
<br />21c. WAS AN AUTOPSY Pats€ORMEP'
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAILA
<br />TO COMPLETE OAUSE OF DEATH?
<br />❑ YES NO
<br />IURY-At home, farm, street, factory, office building, construction site e*#;(Sf ifY).,'
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />J( IV 6 2022
<br />TOMS best of my knowledge, death occurred
<br />and due td•theeauae(s) Stated. (Signature and
<br />Iniel M. Hershberger, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH'
<br />23c. TIME OF DEATH B 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED AEAp
<br />a'3t
<br />11:38 AM at the time, date and plate
<br />Title) � w g low.� the beBia of examination and/or investigation, In my opinion death d4Gurred at
<br />$,2255 the trine, date and place and due to the cause(s) stated. (Signature atilt" flue)
<br />�8
<br />TH? 26a. HAS ORGAN: OR • • ATIION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />KNOWN ❑YES • %i • Not Applicable If 28a Is NO ❑ YES ❑ NO
<br />or Print
<br />Nebraska Medical Center, Omaha, - raska,�68198
<br />28. ElID TOBACCO USE Cl ..NTRIBUTE 10 THE DEA
<br />YL$ NO ;.❑ PROBABLY 0 UN
<br />T ME, Tfl1, AND AADRE8S OF CERTIFIER (Type
<br />Daniel M Hersttberger, MD, 985990
<br />28a. REGISTRARS SIGNATURE'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 8, 2022
<br />0)
<br />
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