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of hMM 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 5/13/2016 LINCOLN, NEBRASKA 201703916 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH awl STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Arthur Dale Sweet eV 7. SOCIAL SECURITY NUMBER 507 -34 -5150 Sb. FACILITY -NAME (If not Institution, give street and number) Edgewood Vista Grand Island 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ® Other (Specify)ASSISTED LIVING 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 68803 9a, RESIDENCE . STATE • Nebraska LL 9d. STREET AND NUMBER a 2108 West 10th Street 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married M ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown a E 0 0 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link) No 15. METHOD OFO)SPOSITION ❑ Burial ] Donation ® Cremation ❑ Entombment ❑ ; Removal ❑ Other ( 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska d. [ NJURY ATNORK? D O NO 20. IF FEMALE: I= • ❑ Not pregnant within peat year t 0 � Pregnant at time of death U Not pregnant, but pregnant within 42 days of death Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant *thin the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) u 23a. DATE OF DEATH (Mo., Day, Yr.) April 16.2016 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH April 18; 2016 05:53 AM O 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) Trams S Hageman, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) MOS. 83 5b. UNDER .1 YEAR 9c, CITY OR TOWN Grand Island 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 DAYS 9e. APT. NO. 28a REGISTRAR'S SIGNATURE / _ 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) April 16, 2016 July 2, 1932 !' 8. DATE OF BIRTH (Mo,'Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Olga Petersen • 11. FA:THER'S -NAME IFfrst, Middle, Last, Suffix) d Clarence Sweet L 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Minnie Maydean Douglas 14a. INFORMANT-NAME Olga Sweet 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Crematory >' Grand Island STATE Nebraska CAUSE OF DEATH (See instructions and examples) 1 18. PART 1. Enter the'ehalh of Events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one deuce :ona line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final 2 ) Alzheimer's Dementia disease or condition resulting in death) Sequentially list gooditions, if any, leading to the Cause listed': • on linen. �� DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) Enter the UNDERLYING CAUSE : (CiseaSe Or injury :that inhieted the events resukmq in death) DUE TO, OR AS A CONSEQUENCE OF: LA ST ::: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. APPROXIMATE INTERVAL onset to death Years onset to death onset g death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES[ NO 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 122c. 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 1613. LICENSE NO. 2113, IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian Other(Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) April 19, 2016 1 7b. Z)p'Coda 68603 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E] NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRCNOUNCEN DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e, On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR 4 Mcl,; Day, Yr.) April 25, 2016