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<br />STATE OF NEBRASKA
<br />f ,,thre IN ` l41IrI11r11tt11"
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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 DEPOSITOR? FOR VITAL RECORDS
<br />202206759;
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />DATE l7F ISSUANCE
<br />th 1202
<br />LINCOLN,, NEBRASKA
<br />5b.' UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />L CERTIFICATE OF DEATH
<br />1. CEDENT'S NAME (First, Middle, Last, Suffix)
<br />DOnairf Phillip Carter
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ba. AGE - Last embus*
<br />76
<br />5c. UNDER 1 DAY
<br />WoodE ver, Nebraska
<br />L '
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />16 068381
<br />3. DATE OF (ATfi
<br />September 21.2016
<br />8. DATE OF BIRTN t o., Dayi Yr )
<br />June 4,
<br />7 SO;CIA6C)!RITYNUA98ER
<br />5552417
<br />8b. FACIUT PIAME (if tibt Institut10tr glue street and number)
<br />CH) Health Neb[aska Heart
<br />Bc CITY OR }4WN OFOEA'TH (include Zip Code)
<br />OthDDin 68526
<br />9a. RESIDENCE -STATE
<br />Nebra$1
<br />9d '5'BEET ND NUMBER
<br />210We12thSt
<br />10ti,:MARITA1;:STATUSAT TIME OF DEATHj] Married 0 Never Married
<br />0 Married but separated [(Widowed 0 Divorced 0 Unknown
<br />11. FATHER'it-)AME (Feist, Middle, Last, Suffix)
<br />John Jules Carter Jr
<br />9b. COUNTY
<br />Hall
<br />8t PLACE OF DEATH
<br />HOSPITAL ®:inpatient
<br />0 ER/Ou patient
<br />0 DOA
<br />13. EVERIN S ARMIIEr. FORCES? Give dates of service If Yes.
<br />(Yea, No r Unk.) NO
<br />15. METHODi F RISPQSITIQN
<br />[ :BUriat ODDnallon
<br />e' Creme art O Entombment
<br />�f Removi t I]'Other (Specify)
<br />9c. CITY OR TOWN
<br />Wood River
<br />OTHER [] Nursirig Home/LTC
<br />O Decedent's Harte
<br />Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />'Mb. NAME OF SPOUSE Mint, Middle, Last, Suffix) If wife, give
<br />Gwendolyn Janice Shiers
<br />112. MOTHER'S -NAME (First, Middle, Maiden ()unlink))
<br />Gladys Deenler
<br />14a. INFORMANT -NAME
<br />Gwendolyn Janice Carter
<br />a, EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BML Cremation Service
<br />1.7a. FUNERAI HOME NAME AND MAILING ADDRESS (Street, City or Town, State),:,
<br />Apfe)•i~u lerOI HOme, 1123 W, 2nd, Grand Island, Nebraska
<br />18.PARTtE
<br />reepk
<br />INkdED(ATE
<br />dI4444e er aion reatdufl4
<br />In &Bah)
<br />Sequentially h it conditions, if
<br />rqi any .leadnly tbs caw; lydpd
<br />dDl onlitiea
<br />18b. LICENSE NO.
<br />CITY 1 TOWN
<br />Lincoln
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b. RELA
<br />Spouse
<br />180. DAT
<br />Septem
<br />iy,Yr)
<br />:2015':
<br />ATE
<br />Nebraska
<br />170.74p:000
<br />chain of events- 4baeses, klardea, or complication -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rest, or ventricular tlbdkatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional lines -if ne eaaarv:.
<br />IMMEDIATE CAUSE:
<br />pima a) Cardiogenic Shock
<br />Emarme UNm
<br />(dieeaa8'ar:inJ
<br />dt
<br />the events real
<br />iT7a LAST
<br />18.AARTI(..
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />b) Myocardial Infarction
<br />DUE.?
<br />a01
<br />(ArCONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />OYf ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not restating
<br />IFFE
<br />❑ : NaE Ptsgtunf vdddit p951 year
<br />O Pregneflt t the drlkain
<br />0 Nat Dreg dt; but piagirent within 42 days of death..
<br />Not pregtBnt, but pregnant 43 days to 1 year before death
<br />Unknown k:pfagnatd within the past year
<br />224.fATEOPINJURY (Mo<, Day, Yr.)
<br />22e. DE'
<br />21a. MANNER OF DEATH
<br />® Natural O HomkTH
<br />Accident 0Pending Investigation
<br />0 suicide Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE; OF INJUR
<br />HOW INJURY OCCURRED
<br />onsotts death
<br />3 Days
<br />1 onset to death
<br />the underlying cause given in PART L
<br />21b. IF TRANSPORTATION INJURY
<br />D*Lver/Operator
<br />© Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />19 WAS ,MESIOALEXAMINER
<br />:::
<br />OR CORONKKtIONTA4",9'1I3'l
<br />0 YES
<br />21c.WAS ANI
<br />©YEs
<br />21d. WERE AUTOPIIIT'FAXNGS MAKABLE.
<br />TO COMPLETE' CAUSE OF DEATHS
<br />❑ YES [1:,140...
<br />t home tarn, street, factory, office building, construction alta, etc (S fy
<br />22f, LOCA TKiikl' OF INJURY -STREET 8 NUMBER, APT.NO.
<br />2 DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 2016
<br />CITYITOWN'
<br />23b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />l btember 23.2016 03:08 PM
<br />230 End beat of 1ny knowledge, death occurred at the time, date and place
<br />and sue 101 eta stated. (Signature and Title)
<br />Mui Jain, MD
<br />25. DID TOBACCO USECONTRIBUTE TO THE DEATH?
<br />Ii YBS Q NO }p PROBABLY l UNKNOWN
<br />27. NAMS,T1-1t4 AN► %1D. REBS OF CERTIFIER (Type or Print
<br />Rnu) Ja I MCS, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />28a REGIST(
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME
<br />24e. On the basis of examination and/or invastig tion, In my opinion'
<br />the Shia, slate and place and due to the tiause(4) stated. (Signet
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />®YES ONO
<br />P CODE
<br />UPcED DEAD..
<br />28b. WAS CONSENT
<br />Not Applicable If 28818140 ..1t<
<br />. DATE FILED BY REO (Mo.. ,Day, Yr,)
<br />September 28, 20160
<br />
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