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ettlefitc STATE OF NEBRASKA WHEN THIS '" COPY CARRIES THE RAISED SEAL 1F THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 04/08/2016 LINCOLN NEBRASKA STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ,SgE.ST4TI w , %w 41 4, 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Archie Daniel Lind PART I Ender the chain of eve is.- diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, orventrieujar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lines Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL onset to death 5 Days 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Paul, Nebraska 7. SOCIAL SECURITY NUMBER 508 -48 -1341 lib. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center W 8c. CITY OR TOWN OF DEATH (Include Zip Code) o Grand Island 68803 9a. RESIDENCE -STATE tit z Nebraska 9d. STREET AND NUMBER A 4020 Boston Circle d 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. u (Yes, No, or Unk.) No B 15. METHOD OF DISPOSITION F ❑ Burlai ❑ Donation ® Cremation ❑ Entombment ❑ Removal ;:❑ Other {Specify) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c ) (disease or injury that initiated. the events result n in death) LAST 20. IF FEMALE: ❑ Not pregnant wittim past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death ❑ Not pregnan but pregnant 49 days to 1 year before death ❑ Unknown if pregnant within the past year ce E a 22a. DATE OF INJURY (Mo., Day, Yr.) A22d.INJURYATWORK7 OYES QNO 28a. :REGISTRAR'S SIGNA 5a. AGE Last Birthday (Yrs ) 78 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separatedj;. ❑ Widowed ❑ Divorced ❑ Unknown 22b. TIME OF INJURY 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) April 1, 2016 23b. DATE SIONEO (Mo., Day, Yr.) April 4, 2016 23c. TIME OF DEATH 07:25 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Isaac J. Berg, MD 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 9c. CITY OR TOWN Grand Island DAYS HOURS e. APT. NO. 16a. EMBALMER - SIGNATURE Not Embalmed 2. SEX Male 5c. UNDER 1 DAY MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day Yr.) April 1, 2016 6. DATE OF BIRTH (Mo,, ;:Day, Yr.); November 7 ❑ Hospice Facility 9g. INSIDE CITY .LIMITS ® YES ❑ NO 10b. NAME OF. SPOUSE (Fii Joyce Boley t, Middle, Last Suffix) If wife, give maiden name 11. FATHER'S -NAME (First,' Middle, Last, Suffix) Vance Lind 1 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Myrtle Mortensen 14a. INFORMANT -NAME Joyce Lind 16b. LICENSE NO. 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day Yr.) April 4, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY/TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)!' Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH jSee instructions and examples) in death) Sequentially list conditions, if any, leading to the cause listed` n Snarl DUE TO, OR AS A CONSEQUENCE OF: 10) End Stage Renal Disease onset to death 3 Years onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to (loath> 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Stroke,_, 211s. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES 0 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ Y E S ®NQ 21c. WA AN AUTOPSY PERF ORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE bF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 122f. LOCATION` OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination andlor investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo..Oay, •WW.)i • April 7, 2016