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STATE E OF NEBRASKA
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<br />WHEN FINIS COY :a•itO•RIES THE RAISED SEAL OF STATE OF:NEBRASKA, ITCERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE`cO• P?: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 />;DATEOPI> SWINCE'
<br />\ 12/16/2024
<br />LINCOLN, NEBRASKA
<br />202406648 SARAH '.. ASSISTANT STATE REG S9'
<br />DEPARTMENT OF HEALT
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />C ERTIFICATE: .0F. DEATH.
<br />t,DECEDENTSNAME% (Firat Middle, Last, Suffix)
<br />Charlet ....hitcher
<br />4. CITY AND STATE \ OR'TERRiTORY, OR FOREIGN COUNTRY OF BIRTH
<br />hKeirnity, Hebrassa :.
<br />*SOCIAL rti..N S
<br />508=42 2837::
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />dt.
<br />is
<br />8b. FACILITY -NAME (If notinatitudon, give street and number)
<br />12Z ..Plantation P Doe
<br />Sc. CITY OR::TOWN OF: PEAT
<br />Grand lalafirl. 51103
<br />9a, RESIDENCE -STATE
<br />(Inci
<br />Zip Code)
<br />96.COUNTY
<br />Hall
<br />99. S'1`REETA;ND raial18ER>:'
<br />,1220 P1antatlori:Place
<br />10t, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑Widowed 0 Divorced 0 Unknown
<br />F lt: E :':3-NAME <fE:ilst, : Middle, Last, Suffix)
<br />JOT!..'Whitener
<br />13. EVERTN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 02/04/1958-02/03/1964
<br />r6:
<br />ETHOD OFTHSPE .SITIO;N
<br />Donation:;
<br />�ryry Crar al on ; ' Eiiloptbmsnt
<br />Removal 0 Other (Specify)
<br />89.
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACiE OF DEATH
<br />HOSPITAL :0Inpat►ent
<br />0 ER/Outpatient
<br />DOA';.
<br />Sc. CITY OR TOWN
<br />• . Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATff4Mo ; t?( yi Yr : > *''
<br />December 4,44
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 17,1*3$.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Re.: APT. NO.
<br />91. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Harriet Jean Pogue:.. :.
<br />pica Faaillt i
<br />osaistoe i lT'1 LiMi7S;;
<br />> Y No
<br />en nerve ;
<br />I
<br />. 12.. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />HuIda ;;Amelia Carlson
<br />14a. INFORMANT -NAME
<br />Jean Whitcher
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services'
<br />lla. FUNERAL SOME NAMEAND MA LING ADDRESS (Street, City or Town, State)
<br />All -Faiths Fu #er::ei; Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />l:s . LICENSE NO.
<br />:1495
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />I4. PART I. Enter the chain of events- die , injuries, or complications -that directly caused the death. DO NOT ether terminal events such as cardiac arrest,
<br />respiratory street, or Ventricular fibrallon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />;IMMEDIATE CAUSE:
<br />}Alzheimer's disease
<br />ion %sdlnnp> `
<br />In death)
<br />Sequentially list conditionf, B.
<br /><Rt1y, leathngto:th uta:usa;llateej�
<br />•bn liners: ....
<br />•'Enter tae:t33111ERLYENG CAUSE
<br />tdiseasa or injury that initiated
<br />the events resulting in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />S. PART 1). OTHER SIGNIPR ANT CONDITIONS-CondltIons contributing to the death but tot resulting in Me Underlying cause given in PART 1.
<br />depression, hypertension
<br />*0. IF FEMA ;
<br />Ndt.pre n4nt;wttltin;pi+tyear:.
<br />p.«.,0 ii it tints' Or rieyllt :: .
<br />0 Not pregnant, bud pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown.n prig dint at! r;l a pest year
<br />ilitiTE CcEINIJRY{Nlc,:.pa
<br />22d. INJURY AT W
<br />OYES . 0
<br />IRK?
<br />21a. MANNER OF:DEATH
<br />Natural ❑ Homicide .
<br />❑ Accident 0 Pending lnvestlgiiti n
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 L SCATION OF:;INJURY; STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />December 4, 2024
<br />CITY/TOWN::
<br />2Tb, DATE:Sissies (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />'bekn let? '2024 12:00 NOON
<br />IWOUtt0t.4WtiitNvladge, dath occurred at the time, date and place
<br />end:0:4It to iliR.lipale) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />21b,,:IF.TRANSPORTATION INJURY
<br />❑:.t,luar/pperator
<br />Isprhger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY -At hotn, farm,
<br />14b. RELATION
<br />Spouse
<br />16c. DATE (410442 My: Yr.i
<br />December
<br />STATE
<br />Nebraska
<br />APPROXIMATE TERVAL
<br />onset
<br />lox
<br />onset to death
<br />Onset tO dt111
<br />19. WAS )MMEOICAL.S AMINER
<br />OR CORONER CONTACTED?
<br />❑ YES GI No
<br />21c. WAS AN AUTOPSY-F.ERFORRM
<br />YE
<br />S
<br />21d. WERE AUTOPSY PMICiI4 S AVAILABL'E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑ No*
<br />t, factory, office building, constru
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />244. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />If>«#SEte
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED::
<br />.
<br />24e.pn thil'Mils of examination and/or investigation, in my *Men death
<br />the time, date and place and due to the causes) stated. (Signature 5M) Tgt1)
<br />21 L DiD;;TgiBACC{, "USE;CO(tiTRIBUTE TO THE DEATH?
<br />., ::YE t-3
<br />❑. 5.®.:RIO;; ?'t 1;;;$ROBABLY 0 UNKNOWN
<br />2, . NAME, T1ff),.E"i�114b xpeaasS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR ISSUE DONATION :BEEN :CONSIDERED?
<br />❑ YES ®NO
<br />!t-44 ,%7'.s>�
<br />28b. WAS CQNSENTt1tRANTECSf'.:<
<br />Not Applicable If 26a is NO In YES N
<br />28b. DATE FILED BY REGISTRAR:;(
<br />December 11, 2024
<br />SHIP TO DECEDENT
<br />
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