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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANLZ,fflf�rFX1 A( �S,ERV.TCES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OFTHE ORIGINAL RECORD ON FILE W17"H THE NEBRASKA�@f�i9l�Tl►��T� f9P�' lo-�9 ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VII�PL,R�ORDS.. ,"�' , a
<br />� �F� �.�,�,,��
<br />DATE OF ISSUANCE �� ' C'„ "�"" ��.� N , ,
<br />05/29/2012 ST.AiW_ES' S. COOPEk 4*•"�
<br />2 012 0 4.� �� ASSd3�AlVT �'/,'A��GI� STRAR r `; �,
<br />DER'�1l�fMENT�b��l �T�NLT �;: r�'
<br />LINCOLN, NEBRASKA HUI�I�S�RVICES ,''' �' r:+ r�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES � �? n ,_� 1 ��.�� �y •� ��� 12 b1871
<br />GCIZIItIGAI t Vt UtAI tl " p "�s t^ •'...• •
<br />1. DECEDENTS (Fhst, Middle, Last, Suffix) 2. SD( ��; �, 3: • �"O� DEATH (Allo., Day, Yr.)
<br />Doroth Joan Arndt Female '' ��May,�2; 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Ba. AGE - Last BlRhday b. UNDER 1 YEAR Sc. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS ANNS.
<br />Garrison, North Dakota 80 October 18, 1931
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />502-26-1203 os H P AL� 0 irtpaueM OTHER ❑ Nursing Home1LTC � Hoapice Fatlllly
<br />Bb. FACILITY-NAME (H rrot Instltutlon, glve atreet a� m�m6er) � FWOutpaUerrt ❑ DecedenPa Home
<br />�
<br />� Saint Francis Medical Center ❑ �A � �
<br />v
<br />� 8c, CIIY OR TOWN OF DEATH pnelude Zip Code) Sd. COUNTY OF DEATH
<br />e Grand Island 68803 Hatl
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />7 9d. STREE� AND NUMBER e. APT. NO. 8L LP CODE 8g. INSIDE CPTY LIMITS
<br />LL 4301 Claussen Road 68803 ��s ❑ No
<br />a�'
<br />. 70a. NWRRAL STATUS AT TIME OF DFATH � Marrled ❑ Never Marrted 10b. NAME OF SPOUSE (First, Mlddle, Last, SuHbc) H wHe, give malden name
<br />� ❑ iuiamea but separated ❑ vnaowea ❑ o�or�a ❑ Unknown Erhart J Amdt
<br />�
<br />11. FATHER'S-NAME (FUst, Middle, Last, Suff6c) 72. MOTHER'S-NAME (First, Mlddie, Maidan Sumame)
<br />� Joseph Kastner Marcella Ftscher
<br />°� 13. EVER IN U.S. ARMED FORCEST Give dates of service Ii Yes. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />� �res, No, or unk.) No Erhart Amdt Spouse
<br />,$ 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE N0. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burial ❑ Donadon
<br />Not Embalmed May 23, 2012
<br />� Cre�tlon ❑ Errtombmerrt �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� Removal ❑ Other (Specify)
<br />Centrai Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, C or Town, Sfate) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUS OF DEATH See Instructions and ekam es
<br />1& PArtT 4 Enmr the simin ot eve�rte--0I�s loJuHes, or eompllwUons4hat dlrecUy eaused Gre tleath. DO NOT arrtar terminal eveMa eueh ae eardiae arteat, ; APPROXIMATE INTERVAL
<br />respUeMry arrest, or veMrlcular fibrtllatlon wtthout ehowing the etlotogy. DO NOT ABBREVIATE E�rter only wre ceusa on a Ilne. Add eddlUonal Ones H�ry.
<br />IMMEDIATE CAUSE: � o�et to death
<br />IIaAEED1ATE CAUSE (Fl�ml 8) Sepsis ; Days
<br />dlsea� or conditlon reaultl�
<br />in deau�) DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />sen�eM�ei�r i�ae �o�a�no�s, ir b) Pneumonia
<br />am. �eaa�ng w tne cause nsted ;
<br />on Iitre a DUE TO, OR AS A CONSEpUENCE OF: � o�met to death
<br />EnOer the UNDERLYINO CAUSE ��
<br />(dlseaSe orinJurythatlntdaOBd
<br />the eve�ps reaultlng in d�th) DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />� d)
<br />18. PART It. OTHER SIGNIFlCANI' CONDITIONS-Comiklons corrtributlng to the death but not reaultl� In the uMerlying cauae given In PART I. 18. WAS MEDICAL EXAIWNER
<br />Renel Failure, Pieural Effu&ion, CollUs, Diabetes OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />LL 0. IF FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />� � Not V�eBnant wffhin P� Y� ��i p Ho�maae ❑ o�.io��►o. � res � No
<br />IL Pregnarrt at tlme of death � Paeeenger
<br />V � Accide�rt � Pendl� Inveatigatlon
<br />�+ p Not P�B�. 6ut PBB�eM wlthln 42 days oT deafh � smdae � cowa noc be aemrmured ❑ nemstr�an 21d.T0 OMPLET CAUSE OF DEA7H
<br />�O � Not a•ee�e. m,c nrea� a9 aeya w� ree. eerere aeaah � onre. csvearr)
<br />� p ves p No
<br />a � � Unknown H Pre9nant wkhln the past Y�
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, tarm, atreet, factory, offlee bullding, construetion aite, etc. (Speci(y)
<br />6
<br />8
<br />.S 22d. INJURY AT WORK? Y1e. OESCRIBE HOW INJURY OCCURRED
<br />p �
<br />�- ❑ veS ❑ No
<br />22L LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) ` 24a. DATE SI(iNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />B � May 22, 2012 � � �
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. T1ME OF DEATH ��� y 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />„ Z Ma 23, 2012 12:58 PM 4<�
<br />�� a . ro �ne �s m my imow�ea¢e. aea�n occunea a� srte ame. daee ami P�ace $�°
<br />he 24e. On Na basla M axeml�ation anAfor Investlgatlon. In my oPlnlon daath occurred at
<br />� and due M the causefa) efeted. (Sig�mture aml Tltle) � � the tlme. date and Piace and due to the causels) stated. (Slgnature and THie)
<br />~ Travis S. Hageman, MD ~ g 6
<br />2. DID TOBACCO USE CONTRIBUTE TO THE DEATH4 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES � NO Not Appllcable H Z8a Is NO ❑ YES ❑ NO
<br />27. , IT D D ER IFIER (P SIC , H 3 STANT, C N S 1 OR A O EY) (Type or Prlrrt
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebreska, 68803
<br />28a. REGISTRAR'3 31GNATURE �+ � 28b. DATE FlLED BY REOISTRAR (Mo„ Day, Yr.)
<br />May 25, 2012
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