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STATE O� NEBRASKA �� 12 0 9 2 3 5
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIF�1
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEP05ITORY FQR
<br />DATE OF ISSUANCE
<br />08/03/2010
<br />LINCOLN, NEBRASKA
<br />. _` �+ .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERYI,CES� '
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<br />�l�'C7N]j4`QI ;S,�RVIGES, IT CERTIFIES
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<br />1, qECEDENTS-NAME (Flrst, Middle, Laet, SuiBx) 2. SD( 3: I�ATE`OFD,�4TH (Mo., Day, Yr.)
<br />Arnold Jerome Harders Male July 2� 2Q10 - -- �:�
<br />4. CI7Y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo, Day, Yr.)
<br />(�'B•) MOS. DAYS HOURS ANNS.
<br />Wood River, Nebraska 83 August 2, 1926
<br />7. SOCIAL SECURfTY NUMBER 8a. PLACE OF DEATH
<br />506 s H0 PIT L mpat�eM OTHER ❑ Ntusi� Home/LTC � Hoapice Faellily
<br />8b. FACILITY•NAME (H rrot Institution, give atreet ami numbery ER/O
<br />� ❑ utpaNent ❑ Decedant's Home
<br />� Saint Fra'ncis Medical Center ❑ oon ❑ otner (specrry)
<br />c�
<br />� 8e. CI7Y OR TOWN OF DEATH pnelude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 8a. RESIDENC 8b. COUNTY 9t. CITY OR TOWN
<br />z Nebraska Hall Wood River
<br />LL 9d. STREET AND NUMBER . APT. NO. 9f. LP CODE 9g. INSIDE CITY LIN�TS
<br />�, 12750 W 13th St 68883 ❑ ves � No
<br />.� 10a. MARRAI, STATUS AT TIME OF DEATH � MarHed ❑ Never Martled 10b. NAME OF SPOUSE (Firat, Mlddle, Last, SuHBc) H wNe, give maiden reme
<br />� ❑ nnamea bu� seParacea ❑ v�ndowea ❑ Dlvorced ❑ unicnown Glorene E Mulligan
<br />� 17. FATHER'S�NAME (Flrst, Mlddle, Last, Suftiu) 12. MOTHER'S (Flrst, Mlddle, Maiden Sumame)
<br />m Otto �larders Marie Eich
<br />Q ' 13. EVER IN U43. ARMED FORCES? Give dates of servlee B Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �1res, No, or unic.) Yes 06/15/1953-03/23/1955 Glorene E Harders Wife
<br />� 15. METHOD pF DISPOSITION 76a. EMBALMERSIGNATURE 18b. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />�,�, � Burtal ❑ DoreUon
<br />Patricia R. Curran 1092 July 29, 2010
<br />❑CremaUOn ❑F�Wmbment �gd CEMETERY,CREMATORYOROTHERLOCATION CITY/TOWN STATE
<br />❑ Remorai ❑ o�,er (sPec�ry) W�Uawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL. HOME NAME AND MAILING ADDRESS (Street, Cltyr or Town, State) 17b. Zip Code
<br />Cuman Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />USE OF DEATH See Instructlons and exam les
<br />1& PAR7' 1. EMer the chaln of ave�dieeasee, InJudee, or compumtlona4hat tllreetiy cauaed the death. DO NOT e�nerterminal everAa weh as mrdlae arrast, ; AppROXIMATE INTERVAL
<br />respiratory�artest, orva�rtriculer flbHpatlon wHhout ehowf� 9�e edolopy. DO NOT ABBI�VIATE EMar onty orre muse on a Ihre. Add adtlklonel Wrea H nawseary. �
<br />fMMED1ATE CAUSE: ; oroet to death
<br />ienmEOwrE cnuse �i e) Acute Hemmorhage ; 12 Hours
<br />di�ase orwnpttfon r�ultlng
<br />In aeatn� DUE TO, OR AS A CONSEQUENCE OF: ; Oneet to death
<br />8equeMlally 11� eonditlone, M b) Gastrointestlnal Bleed E 48 Hours
<br />any, Ieadine W;tire cauae Iiated
<br />on Itne a
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset W death
<br />E�rtertha UNDFCRLYINO CAUSE C)
<br />(d�aease orinJurythatinttiatee
<br />� 81 �"� B �� � d � ) DUE TO, OR AS A CONSEQUENCE OF: : o�reet to death
<br />� d)
<br />�
<br />18. PART U. OTHER SIGNIFICANT CONDRIONS-Comiltlorre coMributlnp to the death but not resultlng In the urMerlying cauae given In PART 1. 19. WAS MEDICAL EXANUNER
<br />abdomena4; aneurysm, DemenBa OR CORONER CON7ACTED?
<br />� ❑ YES � NO
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJ 21c. WAS AN AUTOPSY PERFORMED7
<br />LL
<br />� � Not P�Q�M within P� Y� � Naturol � Homidde � Dfire00PBratm
<br />v ❑ a�a�s � tl� or a� � a�aa�e ❑ P�mne u�n98non ❑��re•� ❑ ves � NO
<br />� [] Na a�e¢�. �rt P�eenaM wunm 4a aaYs ot deau � swc�ae � coWa �roc be aemrm��red ❑ Pedea�an 21d TO OM�LETE CAUSE O DEA HLABLE
<br />� Not P�9�t. but PreBne�rt 4S daye M 7 year 6efore death � Other (
<br />� � unknown k n�e9�M w�mm the n� Yeaz ❑ YES ❑ NO
<br />a 22a. DATE O�, INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, factory, oftice bulldl�, eorreWCtlon ske, etc. (Specfy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�' ❑ YES ❑ NO
<br />22t LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. IDATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo, Day, Yr.) 24b. TIME OF DEATH
<br />a JUIy 25, 2010 ,$ � �
<br />��� 23b.;DATE SIGNED (Mo., Day, Yr.) 23c, TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z :lUl 30, 2010 04:45 PM � a a�
<br />8 �� ."fo the beat oi my Imowledge. death oceurted at the time. date a�M plaee $�j �� 24e. On the bash oi azaminatlon end/or Imestigadon, In
<br />�ntl tlue to the cause(a) efated. (SIB�+re and Tltle) 8 z the tlme, date and place and due to the cauee(e) sfate�d. (SlgnaWre arM TMIe� �
<br />'' Ryan D. Crouch, DO ~ � $
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES '� NO ❑ PROBABLY ❑ UNIWOWN ❑ YES � NO NotAppUeable H26a la NO ❑ YES ❑ NO
<br />2. TITLE AND ADDR ERTIFIER (PHY Y I T R P I IAN R NTY A ype or Pr6rt
<br />Ryan D� Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � y 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />August 2, 2010
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