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<br />_STATE OF NEBRASKA
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<br />WHEN Ells CtPYCARRIES T•NE RAISED SEAL OF STATE OR NEBRASI(A, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COSY OP THE ORIGINAL RECORD ON FILE WITFI THE NE BRASKA DEPARTMENT OF HEALTH AND
<br />::HUMANSERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />GATE G'F /sstml11 E
<br />............. ........ ..............
<br />1 /31 12022
<br />LINCOLN, NEBRASKA
<br />di? i
<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 />1 DECEDENT?$ -NAME (I+rst, Middle, Last, Suffix)
<br />Richard .:;':pale Oltham
<br />CERTIFICATE OF DEATH
<br />4. CITYAND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, N..ebraska
<br />sDCK4 sEOURITY NUMBER
<br />8Q5 36-1899
<br />8b. FACILITY -NAME (Snot Institution, give street and number)
<br />PrimroseRetirement of Grand Island
<br />8c:,'GITY OR T#yWN OF DEATH (Include Zip Code)
<br />Grand lslalld 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d :STRE T Aso NUMBER
<br />:€9 Renee Road
<br />8as`AGE - Last' Birthday.
<br />(Yrs.)
<br />86.
<br />Bb UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLA. CE OFDE 4TH
<br />HOSPITAL ❑:Inpatient
<br />ER/Outpatient
<br />❑ ROA
<br />9b. COUNTY
<br />Hall
<br />1Oa: MARITAL STATUS'''AT TIME OF DEATH ® Married 0 Never Married
<br />0 Mauled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER SAME !First, Middle, Last, Suffix)
<br />Hero i Arthur f iliham
<br />13: EVER1N E.S:ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />96 METNOD OF DISPOSITION
<br />Burial ODonallon
<br />Cremenon ©Entm#ibment
<br />❑Removal Q Other (Specify)
<br />9c. CITY OR TOWN
<br />Doniphan
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3.' DATE OF'DEATH(Iyio.,
<br />January 12 21122'
<br />OTHER 0 Nursing Hour{
<br />0 Decedent's Floc
<br />® Other (Specify)A$$I
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68832
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) 1f wife, give maiden tams
<br />Barbara Magdalene Meyer
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Elizabeth Weeks
<br />14a. INFORMANT -NAME
<br />Barbara Magdalene Gillham
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17ap FUNERALHOME N ME AND MAILING ADDRESS (Street, City or Town,State)
<br />A(1 Faiths;Funeral Home, 2929 S. Locust Street, Grand IslEnd,::Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />CA E OF DEATH Se= ins r l•n n'• =.a
<br />. PART I. Enter the chain of events --diseases, Injuries, or complicationadhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />Isepiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Innes N necessa
<br />IMMEDIATE CAUSE:
<br />fit9MODIATECAt3E(Flnei ; a) acute myeloid leukemia
<br />disease or sandittos rea4 _.._.
<br />1'r1ryt»1��MiTB`:
<br />14b. RewnoeStt P TO D1aCEDENT
<br />Spouse
<br />16c. DATE:(!
<br />January!
<br />Sequentially list condldona, if
<br />any, leadhng to the;cauae:gsted
<br />onfivaa
<br />EntsrMBUNDERI.VING CAUSE'
<br />......e.._ ....._ ...._e
<br />(disease or In)uty titan initiated
<br />the events resulting In 40.10)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)chronic myeloid leukemia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1&PART#, OTHERSIGNIFICANT CONDITIONS -Conditions contributing to thedeath but not resulting in the underlying cause given In PART L
<br />diabetes ,hyleltenside
<br />20. IF.FEMALE.
<br />Nat paagnatn gathb3 past year
<br />© pregnant 03,3bite or erste;:s
<br />O lfoi gr8gnallk but preg nt within 42 days of neat❑ Not pregnant within
<br />but pregnant 43 days to 1 year before death
<br />0 t(nknown i f pragnsnt whh,In the past year
<br />220 GATE tFINJURY (Mo Day, Yr.)
<br />l. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending tnveation
<br />0 Suicide ❑Could not be detegsurmined
<br />22b. TIME OF INJURY
<br />22d.
<br />NJURY AT WORK?
<br />;OYES .ONO
<br />4ICAT(ON CIF
<br />21b.IF TRANSPORTATION INJURY
<br />DrWarloperator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDAL EXAMINEt ;,
<br />OR CORONER'i ONTACT !?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFOR11AED1?.
<br />❑ YES NQ..
<br />(1d. WERE AU Ili AVAIL*B .
<br />TO COM CAUSE OF DEATH?'
<br />❑ YIDS Ll No
<br />22c. PLACEOF INJURY At home, farm ,aitreat, factory, office building, cons
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />liBr STREET & NUMBER, APT.NO.
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />January 12, 2022
<br />CITYtTOVVN.
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />J9nuaPlr O, 2022 08:25 PM
<br />234. Tattle Seek of My lmowl.dge, death occurred et the time, date and place
<br />OW due to tlte:pause(s) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />28. DID...TOBACCO USE.CONTRIBUTE TO THE DEATH?
<br />O yes . ea Q PROBABLY 0 UNKNOWN
<br />il. NAME, TITLEAtoilioi?7R@SS OF CERTIFIER (Type or Print
<br />Rya:WO Ctouoh, 470, 800 N Alpha St, Grand Island, Nebraska; 68803-
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH,
<br />24d. TIME PRONOUPicED DEAD:.....
<br />24e. On the nota of examination and/or investigation, In my opinion deat)r.Ot erred at
<br />rha tine'; date and place and due to the cause(s) stated. (signature 40411(10):_.
<br />26a. HAS ORGAN OR TISSUE DONA110N BEEN CONSIDERED?
<br />❑ YES Ed NO
<br />28a. REGISTRAR'S SIGNATURE
<br />24J7
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO E . YES ©NG
<br />28b. DATE FILED BY REGISTRAR (Mo.,Day, Yr.)
<br />January 25, 2022
<br />
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