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<br />STATE OF NEBRASKA
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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 ME ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S, THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202206959
<br />DATE OFISSt1ANCE
<br />JNCOLN, NEBRASKAi
<br />2022.01087
<br />.64-4,101
<br />SARAN 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 />IR?ENT'a*Aliii tFltst, Middle, Last, Suffix)
<br />erTyt Glenn Muir
<br />4. CITY Mb STATE OR::TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Phillipsburg, Kansas
<br />l CIAi, SECURITY NUMBER
<br />06-66-5932
<br />8b. FACILITY•NAME IE notinstitution, give street and number)
<br />CHI.Health St Francis
<br />8c. girt ORTOWN OF DEATH (Include Zip Code)
<br />Grand Island 688133
<br />RESIDENCE -STATE'
<br />Nebraska
<br />d..STREET ANIS NUMBER:.
<br />1.2 COM anObt.AVenue
<br />eITALESTATOBATITME OF DEATH DU Married ❑ Never Marrled
<br />Married, but aepaffited 0 Widowed ❑ Divorced ❑ Unknown
<br />6a. AGE • LastBirtltday.
<br />(Yrs.)
<br />71
<br />Ab UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />sa. PLACE QF DEATH
<br />HOSPITAL Inpatient OTHER 0 Nursing Horne/LTC'
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other (Specify),
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. [SATE OF DEATH (M#::clay Ytj
<br />December 25, 202
<br />6. DATE OF BIRTH IMo., Day; YI )
<br />August 12,;:19;
<br />9b. COUNTY
<br />Hall
<br />THER'S-N :ME (First, Middle, Last, Suffix)
<br />Donn€e Mutt
<br />13. EVER tN U S; ARMED FORCES? Give dates of service If Yes.
<br />ss, No, or Unk.) NOm
<br />15. METHOD OF DISPOSITION
<br />•1 Burial ;.;; ❑ DotNttlon
<br />OGremation .t3EntontIsment
<br />❑ Removal ❑ ONrer (Specify)
<br />9c. CITY OR TOWN
<br />Grand island
<br />10b. NAME OF SPOUSE (Met,
<br />Rita Havel
<br />14a. INFORMANT -NAME
<br />Rita Muir
<br />18a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />8d. COUNT
<br />Hall
<br />Se. APT. NO.
<br />Middle,
<br />OF DEATH
<br />9E ZIP CODE
<br />68803
<br />9a IN91
<br />(Y:L1Mri'S':f
<br />12. MOTHER'S -NAME (First,
<br />Gertrude Fisher
<br />Middle, Maiden Surname
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand, island City Cemetery
<br />a. FUNERAL HOME NAM.6 AND MA LING ADDRESS (Street, City or Town, State)
<br />AREAE r'uner>ll Norrie; 1123 W. 2nd, Grand Island, Nebraska •
<br />CITY 1 TOWN
<br />Grand Island
<br />14b. RELATIONSHIP
<br />fe
<br />46c. DATE
<br />December < 2021
<br />GEDENT'
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART L Enter the chain of events- diseases, Injuries, or compllcatlonsdat 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. Biter only one cause on a line. Add additional (Merge necessary.
<br />. IMMEDIATE CAUSE:
<br />a) Pulseless electrical activity
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR A CONSEQUENCE OF:
<br />Sequentially list conditions, a b) myocarditis
<br />any, leading to the cause listed
<br />on tine a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ef3teethe t NDERLYINO•CAUSE
<br />(disease or injury that Inmates;;
<br />the events rogueing In death} DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART Ir OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death l
<br />Ispetes type 2 hypdrtertaion, hyperlipidemia, obesity, hypothyroidism
<br />nderlying cause given in PART I.
<br />0. IFFEMALE::.
<br />'MOL paegnam wltnln: Pius year
<br />:Privont0tlmeofdeath :
<br />tee Stegnatlr but pragrant within 42 days of death:
<br />Not pregnant, but pregnarlt:43 days to. 1 year before: death
<br />Itnown if.p!eananrtr ithiothe past year
<br />22a. ixATE OF tNJURY(Ms Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES DNO.
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />11 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />214, IF TRANSPORTATION
<br />© Dltverioperator
<br />© Passenger
<br />CI:Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />99. WAS MEDICALEXAMINW
<br />OR CORONEii CONTACTED,
<br />(� YES I1 N ?
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®No
<br />21d. WERE AUTOPSY FININNGS AVM.ABLE
<br />TO COMPLETE GAUZE Or DEATH'
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY•At home,farm, street, factory, office building, construction site, etc (Slogclfy)'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CATION OF INJURY STREET & NUMBER, APT.NO.
<br />in:.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 25, 2021
<br />cITY/TOwN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Fitobruary.3 2022 10:19 M
<br />Tours bet* ormy knowtedge, death occurred at the time, date and place
<br />at tdu tottte cauesis) stated. (Signature and TSIs)
<br />Jay C. Anderson, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATHNCE.,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUD
<br />344 An the basis •
<br />of examination andlor Investigation, 'IR:MY opinion death oddurrei
<br />the limn e, date and place and due to the causes) stated. (Signature grid ".)ItM)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES fa NO PROBABLY 0 UNKNOWN ❑ YES ®NO
<br />3r1NAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENTGRANTPD?
<br />Not Applicable if 26a Is NO ❑ YEE,,
<br />N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 3, 2022
<br />(A)
<br />
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