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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 />BEA 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 />............ ....... .............:.
<br />............ ...... ................
<br />DAT1; OFISSUANCE
<br />11 /29/2022
<br />GJNCOLN, NEBRASKA
<br />gg�++
<br />8
<br />202208636
<br />044j7 614,4 za
<br />SARAH BOHNENKAMP 7
<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 />1. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Clales RPdtlatd C:randeli
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Harrisburg, Nebraska
<br />1.SOCtAL SEteURITY NUMBER
<br />507 40-6693
<br />5a, AGE - Last:Birthday
<br />(Yrs.)
<br />86
<br />8b. FACILITY NAME (If not Institution, give street and number)
<br />4223 Spur Lane
<br />6c. CITY OR TOWNOP DEATH (Include Zip Code)
<br />Grand island 68803
<br />90..RESIDENCE-STATE .
<br />Nebraska
<br />IL ;STREET AND NUMBER.
<br />4223 Spur Lane <
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE QPDEATH
<br />HOSPITAL ❑;inpattant
<br />0 ER/Ou patient
<br />0 DOA
<br />10a MARITAL STATUS AT TIME OF DEATH I Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. F..i. HER'S.M. ME (First Middle,
<br />Joseph DOWie Crandall
<br />Last, Suffix)'
<br />13'€VERIN U II ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 08/27/1958-06/06/1961
<br />15. METHOD OF DISPOSITION
<br />❑ Buda( ❑ Donation
<br />I Cremation Entombment
<br />I] Removal !' ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF pEATH.ENto., #ey Yr
<br />November '18, 2022
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 21, 1936
<br />OTHER 0 Nursing Horne/LTC
<br />® Decedent's Home
<br />0 Other (Speclty)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />90. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden hmiu4
<br />Gay Petersen
<br />Hosptpe Faor#1ty
<br />9f. ZIP CODE
<br />68803
<br />9g ifiefo CITY#tMItS:
<br />1.184 (3470.-„,
<br />12. MOTHER'S.NAME (First, Middle,
<br />Ede Kilburn
<br />14a. INFORMANT -NAME
<br />Gay Crandell
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL: HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Al) FaithsFuneral Home, 2929 S. Locust Street, Grand Island,; Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />Maiden Surname
<br />CAUSE OF DEATl (See i.nstructlens and examDles)
<br />19. PART I. Enter the chain of evge�.-dIoeasee, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardla5 arrest,
<br />respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines x necessary.
<br />IMMEDIATE CAUSE:
<br />00Mf01ATECAt)SE(Ftnat a) Parkinson's disease
<br />disease or abadltIsn resulting;
<br />aegilentially list conditions,)
<br />any leading to the cause het
<br />on tItte a ..
<br />EdtetthSUNDEImt'riNG CAUSE..
<br />(disease -or Injury that im'bsled
<br />the events resulting In death).
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A' CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTtk OTHERS(GN(F(CANT CONDITION
<br />Hypertension; Diabetes II
<br />20. IF FEMALE ...
<br />iii •Not ptagnel* witide paot;pear
<br />❑ Pfegnant at ajne of 4aatk
<br />❑ .Not pregnant; but p(pgnerit v{ahin 42 days of death
<br />❑ NM pregnant, but pregnant 4S days to 1 year before,death
<br />❑:Unknown 11,pregna t wi hin the peat year
<br />14b. RELATIONSHIP TO DECENT
<br />Spouse
<br />16c. DATE (M(X,:DayYr )
<br />Nova `r22 2022
<br />H 97ATE '
<br />Nebraska
<br />170. Zf(s;Code:
<br />6880
<br />ate
<br />onset **death
<br />onditions contributing to the death but notresuitfrtg to the underlying cause given In PART I.
<br />22a .DATE OF jf #JURY (Mo. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES ONO
<br />22t'
<br />21e. MANNER OF DEATH
<br />® Natural. 0 Homicide
<br />❑ Accident 0 Pending Inveatigetlon
<br />0 Suicide. 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21:b, (F, TRANSPORTATION
<br />SINK/Operator
<br />Passenger
<br />0 Pedestrian
<br />O Other(Specify)
<br />INJURY
<br />19. WAS ME*JCAti'EXAMINER.
<br />OR cokokaa VTACTED?'
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERPORME09
<br />0 YES [ IJO
<br />21d. WERE AUTOPSY FINDINGS AVAILAB
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES QNO
<br />22c. PLACE OF INJURY.At home, farm, street, factory, office building, construction site, etc, (Specli`y;
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />CATION OF INJURY: STREET 8 NUMBER, APT.NO. CITY/TOM
<br />0.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 18, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Novemtrer 22, 2022 02:15 PM
<br />r> To she bast of my knowledge, death occurred at the time, date and place
<br />and due tothe rause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE CONTRIBUTETO THE DEATH? 26a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />VEs
<br />13,
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH,
<br />r
<br />y) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d TIME PRONONCED DEAD
<br />O.I, 0
<br />re lei Gnaw basis of examination and/or investigation, In my opInion death accterad at
<br />8 aro tsne, date and place and due to the causea
<br />s) stated. (Signature ms T e)
<br />8 g
<br />NI! ['PROBABLY ®UNKNOWN
<br />0 YES j] NO
<br />127. NAME,1TrLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Oi3ad Viefh, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebra
<br />28a. REGISTRAR'S SIGNATURE
<br />ka, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Nat Ap) ltoabi if 26e Is NO Q YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 29, 2022
<br />U7
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