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AdVagNakftomdsetau STATE OF NEBRASKA m nszf 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 1/20/2017 LINCOLN NEBRASKA STANLEY S. COOPER 20170387 DEPARTMENT HEALTH AND AR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF I :EALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 [ R EGITRAR'SSIGNATURE 6 acre"- ,n Cote ---] 28b. DATE FILED BY REGISTRA January 13, 2017 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Eldon Richard Kluthe 4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Dodge, Nebraska 7. SOCIAL SECURITY NUMBER 508 -42 -0105 811. FACILITY - NAME (If not Institution, give street and number) O CH( Health St. Francis w 0 -J 9a. RESIDENCE-STATE 9b. COUNTY Nebraska Hall LL 9d. STREET ANO NUMBER 510 Suez Ti toe. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ar ' ❑ Married, but separated', ❑ Widowed ❑ Divorced ❑ Unknown 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 5a. AGE - Last Birthday -(Yrs.) 9e. APT. NO. 19f. ZIP CODE 1 68824 9g. INSIDE CITY LIMITS YES ❑ NO 10b. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name Doris Burenheide T3 11. FATHER'S -NAME (First, Middle, Last, Suffix) V. John Kluthe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Katherine Rebhaussen 14b. RELATIONSHIP TO DECEDENT Spouse Not Embalmed 1 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 13, 2017 E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME 8 (yes, No, or Link.) NO Doris Kluthe a 15. ME1'HODOFa'#ISPOSITION 16a. EMBALMER- SIGNATURE ❑ Burial El Donation ® Cremation ❑ Entombment ❑:Removal ; ❑ Other (Specify) 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) ADfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 1 17b. Zip Code 68801 8, PART F. Enter the chain of events-diseases, injuries, or complications -that directly caused the death. DO NOT entertemdnal events such as cardiac arrest, regpiratery atreat, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. £ Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting m d"I'') ::_.. DUE TO, OR AS A CONSEQUENCE OF: eque list tontudarla, if b) Right Pleural Effusion any, leading to the Cause hated on line a. 22a. DATE OF INJURY (Mo., Day, Yr.) a /Acute Hypoxic Respiratory Failure DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c)Acute On Chronic Systolic CHF (Dise et inyu ry ; ttlat initiated the events resuhing In death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) lschemic Cardiomyopathy 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Acute Renal Failure, Chronic Kidney Disease, Enterococcus Bacteremia, Anxiety, Cholelithiasis, Diabetes, Peripheral Vascular Disease 0. IF FEMALE: 0 Not pregnant within inlet year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death • ❑ Not pregnant, bat pregnant:3 days to 1 year before death ❑ Unknewn if pregnam within the pant year 22b. TIME OF INJURY d. INJURY AT WORK? 0 YES (Q NO 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. fi S U 2 a 0 3d. To the best of my knowledge, death occurred at the time, date and place Z S and due to the cause(s) stated. (Signature and Title( Jay C. Anderson, MD 5. Dlp TOBACCO USE CONTRIBUTE TO THE DEATH? lid YES ❑ NO ❑ PROBABLY ❑ UNKNOWN CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) January 9,_ 2017 23b. DATE SIGNED (Mo., Day, Yr.) January 9, 2017 23c. TIME OF DEATH 12:01 AM tu 5b. UNDER 1 YEAR MOS, 78 8a. PLACE OF DEATH HOSPITAL © Inpatient DAYS ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Cairo 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 2. SEX Male 5c. UNDER 1 DAY HOURS OTHER MINS. 8d. COUNTY OF DEATH Hall 2111. IF TRANSPORTATION 0 Driver /Operator 0 Passenger ❑ Pedestrian 0 Other(Specify) INJURY 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) January 9, 2017 February 2, 193 6. DATE OF BIRTH (Mo., i Day, Yr.) onset to deattl Weeks onset to death Weeks onset to death Years APPROXIMATE INTERVAL onset to death Days 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSYFINDINGSAVAILABLE TO COMPLETE CAUSE OF DEATH ❑ YES ❑ NO STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD t 1 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 OWES 0 Mo bay Yr.) cD OQ