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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OFNEBRASKA, IT:CERTIFIES THE DOCUMENT BELOW TO
<br />':!'3E A TRUE COPY OF TIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />'HUMAN SERVICES, (VITAL RECORDS OFFICE, WHICH IS THE LEGAL REPOS{TORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />6/21/2024
<br />LINCOLN, NEBRASKA
<br />Amended
<br />d
<br />m
<br />'la
<br />4
<br />2 4 0.2 ,r&..
<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. DECEDENTS NAME.... Firat, Middle, Last, Suffix)
<br />ands :Rinne erison
<br />4'CITY.ANDSTATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Thomasville, Georgia
<br />7 .SOCIAL SEGURITy NUMBER
<br />507»62-0253
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />8tb FACILITY+NAME(If not institution, give street and number)
<br />Tabitha At Prarie Commons
<br />Sc.::CITY OR TCWN OF DEATH (Include Zip Code)
<br />Grandis)and 68863
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d,. STREET M1N9 NUMUR'[t
<br />'2706 Brentwood B /d
<br />9b. COUNTY
<br />Hall
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Se PLACE OF rDEATH
<br />HOSPITAL u inpatient
<br />0 ER)Outpatisnt
<br />0 DOA
<br />10a. MARITAL;; STATUS AT TIME OF DEATH I] Married 0 Never Married
<br />0 Msrriad, but separated ❑Widowed 0 Divorced 0 Unknown
<br />11 FATHER S.NAME (First, Mid
<br />Lyle Kerr
<br />13.,EVER IN t) S ARMEDFORCES?
<br />(Yes, No, or Unk) NO''
<br />die, Last, Suffix)
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ DorO tion
<br />Cremation 0l Entombment
<br />Revel u Other (Specify)
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF OEM:MI .r'Day Y,
<br />January 2(4.2.024
<br />6. DATE OF'BlilTit(Mo Day.*)
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (S
<br />8d. COUNTY OF DEATH
<br />Hall
<br />/9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Ob. NAME OF SPOUSE (Fir st,Middle, Last, Suffix) If wife, give mat
<br />Melvin Carlson
<br />1 12, MOTHER'S NAME (First, Middle,
<br />Evelyn Kilpatrick
<br />14a. INFORMANT -NAME
<br />Melvin Carlson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION <'
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a, FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, Stats►
<br />All FaithsFunerai:Home, 2929 S. Locust Street, Grand Island'; Nebraska:•,
<br />CAUSE OF DEATH (See, rittriktiOnt and examples)
<br />iN ciTYLIMiT3'
<br />I Y L a0:
<br />. REL
<br />pain
<br />N#,
<br />16c. DATE (Mt,
<br />Januar 25
<br />111. PART I. Enter Ba chain of even*. -diseases, Injuries, or complications -that directly caused the death. Do NOT enter terminal events such as cardiac arrest,
<br />lesppbatory 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 />a)subdural hematoma
<br />£DIRTE CAUSE
<br />erase or cotglfEMn resukin4r
<br />in
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />Enter theIJNDEI LYINRCAUSE
<br />(dlsaase or injury that mamba.
<br />the evente resulting in dee
<br />LAST
<br />th)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 <PART II OTNER SIGNIFICANT CONDITIONS -Conditions contributing to the:death but notresuN()ng in Ms underlying cause
<br />pelvic fracture subdural hematoma, failure to thrive
<br />20. IF FEMALE:
<br />❑ Notpiegnentwithinpaetyur ,
<br />cr Pregnantattm4M death
<br />u N4tpregaellt butpregriantwithin 42 days of death
<br />❑. Not pregnant, but pregnant 43 days to 1 year before death
<br />❑, Unknown If.pregnant within the past year
<br />22k. DATE OF INJURY (Id , Day, Yr.)
<br />January 8,':2024
<br />22d. INJURY Al
<br />❑ YES
<br />WORT+
<br />NO
<br />21a. MANNER OF DEATH
<br />❑ Natural ❑ Homicide
<br />ig
<br />Accident ❑ Peryding (nvatlgetlon
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />02:00 PM
<br />en in
<br />21b., iF TRANSPORTATION INJURY
<br />❑ Ddver/Operetor
<br />Passenger
<br />❑ Pedestrian
<br />❑.
<br />Other (Specify)
<br />PART I.
<br />19.91148 sM$i2ICAI t IMAiNFtfs`1
<br />OR ER,CONTAGTEI
<br />YES . O
<br />21c. WAS AN AU PSY PE 1.
<br />❑ YES Nti
<br />21d. WEREAUTOPiii.Flibt
<br />TO COMPLETE CAUSE (
<br />❑ YES
<br />22c. PLACE OF INIURY-At Ittilne, farm, Street, factory, office building, construction
<br />Nursing Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Fall occurred at Tabitha Assisted Living
<br />22f' LOO.411011 OF INJURY- STREET 8 NUMBER, APT.NO. CITY/TOWN
<br />3490EWOt St Aa 128. Grand Island
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2024
<br />STATE
<br />Nebraska
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />4
<br />23c. TIME OF DEATH
<br />3: • M
<br />d l`o tits kola of my knowledge, death occurred at the time, date and place
<br />And due to thecauae(s). stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO i'[] PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />03...
<br />24c PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED
<br />to peels of examination and/or Investigation, in my opki
<br />time: date and place and due to the causes) stated. (alp
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />27.;FIAME, TITLE ANDADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Crouch, DO, 800 N Alpha St, Grand Island, Nebraska, 68803:
<br />28a, REGISTRAR'S SIGNATURE
<br />Amended
<br />5/21/2024
<br />5/21/2024
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES . ❑ NO
<br />28b. DATE PILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 31, 2024
<br />Item 22c, "Home" To "Nursing Home" Item 22e, "Fall In The Home" To "Fall Occurred At Tabitha Assisted Living"
<br />sm 22f,;:"2708 Brentwood, Grand Island, Ne 68801" Tit:"3490 Ewoldt St. Apt 128, Grand Island, Ne 88803"
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