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� - STATE OF NEBRASKA
<br />�WHEN THI5 COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAI
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGIIVAL RECORD ON FILE WITH TH��;(ll��i�
<br />HUMAN SERVICES, VI7'AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY
<br />DATE OF ISSUANCE
<br />' ���
<br />JAN fl � 20i� 2 012 0 0 8 3 4 ��g
<br />LINCOLN, NE'BRASKA ����
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALI'H AND HUMAN 8ERVICES ,+�� �x ,+
<br />CERTI lCATE OF D T � � � '' "`,�' "`�;� � � �, ,
<br />1. DECEDENT'S•NAM� (Flrsf,�AAlddle. Leat, SuHlu) 2 9E1( � i G/►TE,OF bEATH (NId..Day.Yr.H
<br />,,� , �
<br />� Harold Arthur Johnson Male December 24, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH 6a pGE.Laet Blrtltdey 8b. UNDER 1 YEAR 8e. UNDER 1 �AY & DATE OF BIRTH (lAo., Day, Yr.)
<br />(lfrs.) MOS. DAYS HOUR.4 ANN&
<br />Aurora, Nebraska � 91 December 19, 1920
<br />7. SOCUIL SECUR(TY NUWBER 8a. PLACE OF DEATH
<br />O SO r J-'I B-HOJr� HOSPRAL: ❑ Inpatlen! OTHER;� Nuraing Home/LTC � Hoaplee FaeWty
<br />V Bb. FACILITY-NAME (If not Inetltutlon, gtva etreet mM number) � [] ERlOutpatlent ❑ Decedent'e Home
<br />� Gaod 3amar3tan vllage-Perkins Pavilion ❑ D0A ❑
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<br />� Bo. CITY OR TOWN OF DPATH (Include Lp Code) � 8d. COUNTY OF DEATH
<br />W Hastings 68902 Adams
<br />� 9& RESIDENCE-STATE 9b. COUNTY 9a CITY OR TOWN
<br />IL
<br />� Nebraska Adams Hastings
<br />.$ 9d STREET AND NUAABER 9e. APT. NO. 81. �P CODE 9g. W91DE CITY Ud11TS
<br />� 900 East B St ' 106 68901 � Yee ❑ No
<br />� 10a MARITAL STATUS AT TIME OF DEATH � AAarrte�l � Nevet Nlarrled 10b, NAAAE OF SPOUSE (Flret, AWdt�e, Lest, SWflx) U wife, giva malden name.
<br />� ❑ �e,em�, but eepareted Q Widowed ❑ cn�o� ❑ u�mow� patricia • Johnson
<br />� 11. FATHER'&NAME (Flrst, . AlpdrOe, Last, 9uftix) 12 MOTHER'3-NAME (Flret, Mid�e, Matden Sumama)
<br />� Ha Johnson Anna Dahlke
<br />m 13. EVER IN U.S. ARA�IED FORCE87 Olve dates M eervlca IT Yes, 1qe. INFORMANT•NAMB 146. RELATiONSHIP TO OECEDENT
<br />F�-
<br />(Yas, No, or Unk) Y@S 01/2011942-10/20/1945 Tom Johnson Sort
<br />1 B. MRTHOD OF biSPOSiTION 18a EAABALMER-S(ONANRE � 18lt, LICENBE NO. 180. DATE (Mo, Cey, Yr.)
<br />�� p �'� ° "' ° 13o't$ December 27, 2011
<br />�CrmneNOn QEMOmbmam °
<br />❑� � 78d CEAAETE , CREAAATORY OR ER LOCATION CITriTOWN STATE �
<br />Cedarview Cemetery Doniphan Nebraska
<br />17& FUNERAL HOAAE NAESE AND MAILING ADORESS (8treef, Ciry or Town, Sffie) 17b. Lp Code
<br />Apfel Funeral Home,1123 W. 2nd, Grand Island, Nebraska 68809
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1e. PAR71. Fster tlre cnatn mave�. d�se�, Inh�. or wmP�ou�Ntl dlbRly emmetl the aeath. 00 NOi emerte�mind evema eueh ae ceNMe mreat. � APPROXI6W7E fMTERVA6
<br />resP�w1aY arteey m vmVieular fmiilAtlon wtthout shmxi� W atloiogy. DO NOT ABBREYINTE. F�rrter anty mm ause on � Wm. AAd Md%lonel Wa H �mceamry. �
<br />IMMEDWTE CAUSE � onaet W death
<br />IMME6IATE CAUSE (Flnel ,% y� /� / i
<br />� �
<br />n deathor conditlon resuttln9 el C.,- b� Q T� /`/ � � v ��.
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<br />DUE T0, OR AS A 9EQUENCB OF: � anaei �o de�ry
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<br />Sequentlalty Iist ecnditiorre, H b) v ��
<br />anY, leading to the cause ffated �
<br />on Ilna a. WE T0, OR AS A CONSEQUENCfl OF: � � onaet to death
<br />` 1 I
<br />FJIt81' �IB �DER�.�� Ci/�u$� Q� � 1 4� '
<br />�dlaease or inJury fhat iNtletetl �
<br />the avante tosuitlng M death) �UE TO, OR A9 A CON9EQUENCE OF: � o�reet to deafh
<br />LAST : �
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<br />18. PART IL OTHER SI�NIFlCANT CONDITIONS-Condidons ooMdbuting to the death 6ut not renWting tn ihe �mderlying cause gfvan in PART C -� 18. WAS MEDtCAL ExAMINER
<br />\./�.ni �_, �/a�C�,J��ClO r[- �� � ,!`� J � ���� OR �RONERCO oA T .�
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<br />W 'z� IF FEMA�E. 27a M OF DEATH "� 71b. IF TRANSPORTATION INJURY 27a WAS AN AUTOPSY ORMEG? �
<br />� ❑ Not P�e9naM withtn Pest Y� ea� ❑ Homiclda ❑ o�o�.aeo� p rES �o _
<br />w ❑Presnm�c as nme or deatn ❑ a�ctaeM ❑ aeimmre �m�esneaeoo ❑ PassenAer
<br />(� 21d WERE AUTOF$Y FtNDINGB AVAILABLE
<br />T w Q Not Pre9�e�rt, but preBnent within 42 daps oT death ❑ Suidde ❑ Coutd not be determined. ❑ PedeaMen TO CODAPLETE CAUSE OF DEATH?
<br />.0 ❑ Not PreB�mn. but P��t 43 days to 1 YBer hatore deafh ❑ �ihe� (SP�tY) [� YE9 ❑ NO i...
<br />� [�Unlmown Kpregnant wlthin the past year
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<br />E 21e. DATE OF INJURY (Mo., bay, Yr.► 22b.11dIE OF INJURY 22c. PLACE OF INJURY-At home, tarm, street, tactory, oftiee buitding, aonehvcUon ette, etc. (8pacHy)
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<br />O 21d. INJURY AT WORK9 TGe. DESCRIBE HOW INJURY OCCURRED
<br />F " ❑ YE9 ❑ NO
<br />22(. L�ATION OF INJURY - STftBET 8 NUmBER, APT. N0. CITYfTOWN STATE ZIP CODE
<br />_
<br />23a DATE OF DEATH (Mo„ Day, Vr 24a �ATE 81pNED (Mo., Day, Yr.) 24b. T1ME OF DEATH
<br />a � � � G- % ( � k' � �' .
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<br />23b. DATE 81ONED (MO., Day, Yr.) 23c.'1169E OF DEATH ,,, �� O 24c. PROI�OUNCED GEAD (A9o., Dey, Yr.) 24d. T1ME PRONOUNCED DEAD
<br />� j i2 _ � Q ��� � m � E
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<br />� v Z3d. To the bent ot my Imowledg& death oc at tinre� date and plece ���� 24e. On the basle oi examineUaa snNOr ImeeUgadon. in mY M�lon death ccwtred
<br />� and due to the caC e(e) tl 1 s p O at the Ume. data eiM P1ane e� dne to the ceuse(s) steted. (Slgnature and Tltle)
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<br />28. DtD TO CCO USE CONTRIBUTE HE DEATH? v' 28a HAS ORl3AN OR TISSUE DO TION BEEN CONSIDERE07 28b. WA9 CONSENT QRANTED? `�
<br />❑ NO ❑ PROB/18LY ❑ UNKNOWN � YES NO '- Not AppReaWe U 28a is Np ❑ YE8 ❑ NO
<br />27. NAb7E, T1T68 AND ADDREBS OF CER77FIER (PHYSICU►N, PHYSICUIN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEI� (Typa w Print) �
<br />° Michael E..'Johnaon M.D. 606 N. Minnesota Suite 1, Hastings, NE 68901
<br />ZBa RFOISTRAR'8 SIONATURE ' 28b. DATE FlLED BY RE618TRAR (Mo, OaY. YrJ
<br />P � • �AN -��ta9�
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