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<br />STATE OF NEBRASKA _ >,
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<br />WHEN MIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP 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 />AA t'E OE ISSiJANCE
<br />LINCOLN, NEBRASKA
<br />a
<br />A
<br />1.' DECEbENTS:iNAME #Phan,
<br />Carol Jean )Mueller
<br />•
<br />202303005
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALT)�I
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Middle, Last, , Suffix)
<br />4. CI1 Y AND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Loup City,. Nebraska
<br />7. SOCIAL SEC{JRITYNU
<br />08-4+7221,
<br />5a. AGE • Last birthday
<br />(Yrs.)
<br />84
<br />8b. FACILITY -NAME {If<rlr
<br />617 Plum Road.
<br />Insfituti
<br />give street and number)
<br />8c. GtTY OR TOWN OF DEATH (Include Zip Code)
<br />Gram Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />8d. STREET ANO NUMBER;:
<br />617 Plum Road
<br />6b.•UNOER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PLACE OF DEATH
<br />HOSE PITAI* D inpatient
<br />❑ ER/Outpatlent
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL SiAT't)S ATTIME CF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />41. FATHER S•NAME (First, Middle, Last, Suffix)
<br />Harry John;.11tliller
<br />13. EVER INLLS, ARMED: FORCES? _ye dates of service if Yes.
<br />(Yes, No, or Una.) No
<br />15. METHOD OF DISPOSITION
<br />a;Buriat ❑Donation
<br />❑ Cremation ❑ Entombment
<br />❑ R Oval ,I ❑ Other (Specuy)
<br />1
<br />9c. CITY OR. TOWN
<br />Grand Island
<br />HOURS
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />MINS.
<br />3. DATE OF DEA'it
<br />April 17, 282'
<br />23 05385
<br />#Ma, DV,Yr.).
<br />6. DATE OP BIRTW(Mo., D.)
<br />December:: ;8, :1:938..,::
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />»spice Fac1i)#y
<br />84INSIDE Ct et *Om a.
<br />I VES ❑ iso
<br />OW NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden tante
<br />Roger Mueller
<br />14a. INFORMANT -NAME
<br />Roger Mueller
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Louise Obermiller
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH I8
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />instructitnsand exa
<br />14b. RELATIONSHIP TO DECEDENT;
<br />Spouse
<br />16c. DATE (Mo.,
<br />April 21, 2023
<br />eek mDle+s)
<br />18. PART!. Enter the Chain Ot events- -diseases, Injuries, or complications -that 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 line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />)MMknlA1'8CA48SFinat a) Metastatic adenocarcinoma colon
<br />dialpge or fdddition resuaing
<br />irtdeatN DUE TO OR AS A CONSEQUENCE OF:
<br />Sequentially Ilst conditions, if b)
<br />any, leading to the causelisted
<br />an untie, ''"•:""" """'":"*"DUE TO, OR ASA CONSEQUENCE OF:
<br />EntertheOlOir.t.TROSSJBE C)
<br />(dieeasaorlNury::tltat hthlatad.
<br />the events resulting In death)
<br />8. PART II OTHER
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Nebraska
<br />Ob. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />StGNIF,jCANT CONDITIONS -Conditions contributing to the death
<br />20.IF FEMALE:
<br />❑
<br />Alt Pregnant 'Within•
<br />ptIstySsr
<br />C Pregnant at S$te of daeth
<br />Nat ptegnadt htit Pilgrim within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before `deal
<br />❑ Unknown h pregnant within the past year
<br />not resulting 1n theu derlying cause given in PART i.
<br />22a :DATE OF INJURY (Mo., Day, Yr.)
<br />220. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f. LOCATIONt
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Inve tigetiott
<br />0suicide 0 Could not be deteimined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />El Passenger
<br />OPedestrian
<br />El Other (Specify)
<br />19. WAS MEDICAL..XA..NER:
<br />OR R CONTACT?
<br />❑ is ;21 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES El NO
<br />21d. WERE AUTOPSY FINOINeS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ...
<br />22c. PLACE OF INJURY -A# home, farm, street, factory, office building, construction si
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />INJURY- STREET 8: NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 17, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Alwin 21.2023
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />05:10 PM
<br />21d. To:the best of my knowledge, death occurred at the time, dab and place
<br />and:�due to the eause(s) stated. (Signature and Title).:
<br />Ryan b Crouch, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES Ii NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />coos zi
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e On the heats of examination and/or investigation, In my opiniond
<br />the time :date and place and dueto the cause(s)stated. (Slgnatu
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27. NAME, TITLEAND ADDRESS OF CERTIFIER (Type orPrint
<br />Ryan b Crouch, DO, 800 N -Alpha St, Grand Island, Nebrask& 88803
<br />28a. REGISTRAR'S SIGNATURE
<br />A.17 62-44.-/Leirthois-4.31..fa-
<br />{peed
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YEAS
<br />❑ so
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 24, 2023
<br />
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