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STATE OF NEBRASKA WHEN THIS' <' COPY CARRIES THE RAISED SEAL OF 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 201607314 10/24/2016 LINCOLN, NEBRASKA avti STANLEY S. C a OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH tti tlr I . UI W U v 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Alan Jeffrey Arens 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Yankton, South Dakota 7. SOCIAL SECURITY NUMBER 506 -92 -1168 8b. FACtL)TY -NAME (if not Institution, give street and number) CHI Health St. Francis 8c, CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska '! 8d. STREET ANTI NUMBER 407 Sycamore Street 1Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married [] Married, but separated ❑ Widowed ® Divorced ❑ Unknown 13. EVER IN U.S.: ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ® ° Burial ❑ Donation ❑ Cremation ❑ Entombment Removal 0 Other (Specify) Enter the UNDERLYING CAUSE (disease •or.Injury that initiated . the events reau xrrttj in death) . LAST ':. _.... ": 20. IFFEMALE: 0 Not pregnankwithm past year ❑ Pregnant at time of death ❑ , Not pregnant pregnant within 42 days of death ❑ Not pregnant but pregnant 43 days to 1 year before death ❑ •Unknown it pmgnant withiNthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22d. .INJURY A? WORK? • © YES ❑ NO Y z u al 0 t3 C7 o O 23a. DATE OF DEATH (Mo., Day, Yr.) October 1 , 2016 23b. DATE SIGNED (Mo., Day, Yr.) October 4, 2016 23c. TIME OF DEATH 02:58 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Travis S. Hademan, MD 25. 010 TOB USE CONTRIBUTE TO THE DEATH? Q YES ❑ NO 0 PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (YrS.) 58 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Katie M. Smydra 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 28a, REGISTRAR'S SIGNATURE /(_ 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient II ER/Outpatient 0 DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Cairo 9e. APT. NO. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ;❑ Other. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 1_ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68824 3. DATE OF DEATH (Mo., Day, Yr.) October 1, 2016 February 7, 195 6. DATE OF BIRTH (Mo., Day, Yr,) 9g. INSIDE CITY LIMITS 12 YES ❑ NO 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arlo Arens 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Arthella Ohm 14a. INFORMANT -NAME Michael Lee Arens 16b. LICENSE NO. 1454 16d. CEMETERY, CREMATORY OR OTHER LOCATION Sacred Heart Cemetery CITY/TOWN Wvnot STATE Nebraska 17a, f'UNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska 14b. RELATIONSHIP. TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) October 6, 2016 17b, Z(p Code 68801 CAUSE OF DEATH (See instructions and examples) 43. PART 1. Enter the - chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arteat, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) IMMEDIATE CAUSE: a) Cardiac Arrhymia APPROXIMATE INTERVAL onset to death Minutes Sequentially list eenditions, if any, leading to the cause listed on Ii iie a. DUE TO, OR AS A CONSEQUENCE OF: b) Ischemia Cardiomyopathy onset fodeatt}: Years DUE TO, OR AS A CONSEQUENCE OF: c) Coronary Artery Disease onset to death Years DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART It. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. CORD, Encephalopathy 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED/ ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. 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 and /or investiga ion, 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 Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (M October 13, 2016 Day, Yr,)