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<br />yllik"i#5ill r,)tttt.le�)§rrlaCg3 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 OPINE ORIGINAL RECORD ON FILE WITH THE Nramisick DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DArB ISSUAN
<br />2/4/2022
<br />LINCOLN, NEBRASKA
<br />202304740'
<br />20220506,E
<br />1,t,.eft
<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 />CERTIFICATE OF DEATH
<br />1 DECEDENT'S-NANIE (First, Middle, Last, Suffix)
<br />Terry Glenn Muir'
<br />4. CITY AND S'T'ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Phillipsburg, Kansas
<br />SOCIAL SECURITY NUMEER
<br />546.66.45932
<br />Sb. FACILITY -NAME (If ttotlnstitution, give street and number)
<br />CHI Health St. Francis
<br />03,T9091 OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />'gd..STREET AND NUMBER
<br />312 COmrYianche Avenue
<br />9b. COUNTY
<br />Hall
<br />5a. AGE • Last:Birthde
<br />(Yrs.)
<br />2. SEX
<br />Male
<br />5b. UNDER 1 YEAR 6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />71
<br />8a, PLACE OF DEATH
<br />HOSPITAL ] Inpatient'
<br />0 ER/Outpatient
<br />0 DOA
<br />10a MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated 0 Widowed; 0 Divorced ❑ Unknown
<br />. FATHER.E8-NAME (Ffrst,:. Middle, Last, Suffix)
<br />Donnte Muir
<br />z. 13. EVER IN U.S., ARMEDFORCES? Give dates of service if Yes.
<br />8 (Yea No orUnk.) No
<br />METHOD O.F DISPOSITION
<br />IJ Butlai (] Donation
<br />Q Crematit []$tet04inent
<br />Q'Remr>vat j] Other (specltY)
<br />HOURS
<br />MINS.
<br />2119050
<br />3. DATE OF DEATlf .(Mo., Day, Yr J
<br />December 25; 2021_
<br />6. DATE OF BIRTH (Mo., Day 1`r )
<br />August 12,;1.950:;
<br />OTHER 0 Nursing Home/LTC;
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />ti ptce Facility.
<br />6c CITY
<br />Ob. NAMEOF SPOUSE (Pkat, Middle, Last, Suffix) If wife, give maiden nante
<br />Rita Havel
<br />1 12. MOTHER'S.NAME (First,
<br />Gertrude Fisher
<br />14a. INFORMANT -NAME
<br />Rita Muir
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAl E AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Heiner, 1123 W. 2nd. Grand Island. Nebraska
<br />a4
<br />16b. LICENSE NO.
<br />1537
<br />Middle, Maiden Sumame),
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b. RELATIONSHIP TO OECEDEN t
<br />Wife
<br />16e. DATE (Me., Day, Yr.)
<br />December 29, 2021:"
<br />STATE
<br />Nebras
<br />1S. PART t. Enter the chain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc.lAdd additional Tines ifnecessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE cAuSE(Flner <. al. Pulseless electrical activity
<br />disease or edndilidn resuiuna; :
<br />*eel"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if ` b) myocarditis
<br />any, leading to thecause listed.:;
<br />bn linea.
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the tit/DEWING CAU. t t
<br />(disease Or item that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />?Z LAST
<br />d)
<br />170, Zip Coda:
<br />WSW
<br />APPROXIMATE INTERVAL
<br />onset torloat#t:i::
<br />Minutes
<br />onsetto death
<br />Days
<br />ath
<br />onset to death
<br />18 PART til. OTHER StGNIFII+ANT CONDITIONS -Conditions contributing to the death but not reeulting in the underlying cause given In PART I.
<br />diabetes type2, hypertension, hyperiipidemia, obesity, hypothyroidism
<br />IF;FEMALE is
<br />Not pregnant withla)fiat year
<br />Q.
<br />Q lteutWnE etrite eddeaat
<br />Q Not etegnaM, but pregdant within 42 days 01 death
<br />]..Not pregram„but pregnanes days to 1: year before death
<br />❑ .;Unknown R ptagnan within flee past year
<br />22a, DATE OF1NJURY (Mo.
<br />22d. INJURY AT WORK?
<br />Oyes ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERCONTACTED?
<br />❑ YES®NO
<br />21p, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 °ROT/Operator
<br />ID Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />0 YES NO ::
<br />21d. WERE AUTOPSY FINDINGS AYAULA
<br />TO COMPLETE CAUSE OF DEATH?
<br />Q' YES Q'NO
<br />Day, Yr.) 22c. PLACE OF INJURY:At home, street, factory, office building, construction site, ebe, ($Pecl44)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22b. TIME OF INJURY
<br />22f. LOCATION OF INJURY:.":STREET B NUMBER, APT.NO.
<br />CITYITOWN'
<br />STATE
<br />a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 25, 2021
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Fl brujv 3 2022 10:1A9 M
<br />Tot* beat of my knowledge, death occurred at the time, date and place
<br />and: due to thgaause(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />D.
<br />D.
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAF)...
<br />. tiler the basis of examination and/or investigation, In my opinion death deettrred at
<br />the t)me,`date and place and due to the causes) stated. (Signature and Ttge)
<br />25. DID TQBACCQ USE CONTRIBUTE TO THE DEATH?
<br />LJ YES; NO .Q PROBABLY ❑:UNKNOWN"
<br />28a. HAS ORGAN QR Tissua • • ATION BEEN CONSIDERED?
<br />0 YES II • .
<br />27. NAME, TITLEANDADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ". Q YES
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 3, 2022
<br />
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