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<br />WHEN THIBM,,COPY CARRIES THE RAISED OF THE STATE OF NEBRASKA, IT
<br />Pgigr1ern*P7:74 • DOCUMENT BELOW TO BE A -TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />pEcosps-DFFICE, WHICH IS THE LEGAL DEPOSITORVFOH-VITALBECORDS
<br />PATE oF1s,wipycE 2 2 4 0 1 2.6
<br />12/4/2020
<br />2 0 2 3 0 3 1 43
<br />LINCOLM NEBRASKA 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 />• DEGEOENrShIAME1F(yat, Middle, Last, Suffix)
<br />'Re/f
<br />.
<br />1[
<br />j
<br />Carpenter
<br />4. art AND STATE OR TERRITORY, QR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />5a. AGE Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.)
<br />80
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER i DAY
<br />HOURS
<br />MINS.
<br />20 16735
<br />3. Dan OF DEMI tMa., pa$4.9:
<br />Novernbei2lZ2020r ?:•i]!!!
<br />3, DATE OF 8IRTH456o.;BOAtif
<br />March 17, 1940
<br />50piodo3E0ottt-ry,NutoBER
<br />10.84.46.230
<br />FAC'iLITY-NAME Of not Institution, give street and number)
<br />CHI Heatth St. Francis
<br />gccirr:N)790NPF.0eATI1 (Include Zip Code)
<br />•Qrandisleiid ISS8D3
<br />9a. easipeNca.sTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ri§j inpatient
<br />O ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC tliHospiett
<br />0 Decedent's Home
<br />Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />3
<br />9d,017aag.rimp:Num
<br />.g735:01teinkid
<br />Ike. APT. NO.
<br />Drive
<br />91. ZIP CODE
<br />68801
<br />'99 INMOEc.::YLMtTS.
<br />10a. MARITAL STATUS AT TIME OF DEATH Ea Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Jonadyne Allen
<br />31. FAirtiER'S4.4AMEIFIret, Middle, Last, Suffix)
<br />Elirot Carpenter
<br />13..E4ER1N IWARBED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/31/1957-05/23/1958
<br />15, METHODOF DISPOSITION
<br />cremation £Entonibment
<br />OemovaJfloth�r(Spacify)
<br />I12. MOTHER'S.NAME (First, Middle, Malden
<br />Audrey Sigmund
<br />14a. INFORMANT -NAME
<br />Scott Carpenter
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />16b. LICENSE NO.
<br />1448
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />170FLINERALBOMkNAME AND MAILING ADDRESS (Street, City or Town, State)
<br />1123 W. 2nd, Grand Island, Nebraska • ••••-:
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or compkationsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory amain, 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 />*040x4TE CAued Fliiet a) Respiratory Failure
<br />igaitimo cunning* mooting -
<br />in
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />goationtiany list conditions, If b)COVID-19
<br />1°I°1°O to I°. °°°°° "tad
<br />11]! DUE TO, OR AS A CONSEQUENCE OF:
<br />EtaffIltatifeDERIA40g/IIE
<br />inhittithathetteraul
<br />:no mins moulting in notion
<br />LAST
<br />Mantle)
<br />14b. RELATIONSHIP TOBEBBDEtW
<br />Son
<br />16c. DATE (Mo7Dtty,Yr.)::
<br />NovembeKi2S:06'
<br />Nebraska
<br />sop ........
<br />APPROXIMATE INTERVAL
<br />ortstettn ds(00.
<br />2 Weeks
<br />onset toi death
<br />2 Weeks
<br />onsetiideeth
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to deadt
<br />18, PART it. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in tha underlying cause given M PART I.
<br />Corenary Artery Disease, Diabetes Mellitus Type 2, Congestive Heart Failure
<br />19. WAS litEDIDALl'EXABINIB5::
<br />OR CORONWCONTAOTECI
<br />OYES gl NO
<br />20. Iff
<br />ErNiiiii#(1564*OKFa4.000
<br />1:FOrs(PIOntIttlinetWOeettC.
<br />akitilPiignant filafitatinent within 42 days of death
<br />0 Not pregnant, but pregnant CS days to year before death
<br />EINMOWoni #firtignOrn within the past year
<br />21a.DEATH
<br />MANNER QF
<br />koN
<br />/Aural Ei Homitide
<br />0 Accident 0 Penning Meeig
<br />0 Suicide 0 Could not be idtet:rmk'n
<br />ined
<br />21b. IF TRANSPORTATION INJURY
<br />0 DriverlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c_. WAS AN AUTOPBY„„... PgRFOKIKarrt
<br />U S
<br />21d. WERE AUTOPSY1FIONGSAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />yes ONO
<br />2.20,43AT5OFM4tTY0044:41Y. Yr}
<br />22b. TIME OF INJURY
<br />22c. PLACEOF INJURY.At home, farm, street, factory, office building, construction eite,.6!e.
<br />22d. INJURY AT WORK?
<br />. .YES,,p119,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />12f. LOCATION OF INJURY STREET & NUMBER, APT NO CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 21, 2020
<br />23c. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />NoViiiitiet:24, ?020 05:01 PM
<br />rad. tome iiiii 0(001:knowledge. death occurrso at the time, date and place
<br />..
<br />W 4titIthialtithaterints(s) stated. (Signature and Title)
<br />' ,..:.:.:.• ...„-
<br />Isaac J. Borg, MD
<br />STATE ZIPCODE
<br />a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME Of
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr,)
<br />24d. TIME PRONOUNCED DEAD
<br />•
<br />24•::9011!kbisis of examination anchor investigation, in my Deimos doethemered4
<br />date and place and due to the tunnels) stated. (SignettmiakrOM) •
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />El
<br />29.
<br />toppeac.co DSECONTRIBUTE TO THE DEATH?
<br />YESPJO 0 PROBABLY 0 UNKNOWN 0 YES NO
<br />27NAMEM : ,IANpApiRes' s O CERTIFIER (Type or Print
<br />iStad..1.41ergAID, 729 North Custer Avenue, PO Box 2339:GrandialandNebraSka, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />11!!!!:: ..........................
<br />0-/14-11
<br />26b. WAS CONSENT GRANTED'?
<br />Not Applicable if 2$a is NO -0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 1, 2020 ',!•R.:•
<br />• •:
<br />CD
<br />0)
<br />
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