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STATE OF NEBRASKA
<br />WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ate
<br />DATE OF ISSUANCE
<br />9/1/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Arlene Bernice Nelson
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hall County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -22- 891.1
<br />Bb. FACILITY- NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />9a, RESIDENCE -STATE 9b. COUNTY
<br />Nebraska Hall
<br />9d. STREET AND NUMBER
<br />4025 Timberline St.
<br />1Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married but separated : El Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />Leroy Grego
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑ Retttoval - ❑ Other ( Specify)
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />PARTI. E the Chain of events -- diseases, injuries, or complications -that directly caused the: death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Pneumonia
<br />disease or condition resulting
<br />n. death).
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />equetltially hat conpdions, if I b)
<br />any, leading to the Cause listed
<br />on line a. _....
<br />Enter the UNDERLYING CAUSE
<br />(diseaseor innury;that initiated;
<br />flue evens resulting M death)
<br />•
<br />LAST
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Dementia, Coronary Artery Disease, Hypertension, Chronic Atrial Fibrillation
<br />0. IF:FEMALE:
<br />❑ Not pregnaetaYnhirpasf year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, Out pregnant within 42 days of tleath
<br />❑ Not pregnant, Dut pregnant days to.1. year before death
<br />❑ U.fknown if pttignantwitht the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d. 11+IJURY AT:WORK.7 :
<br />YES LINO •
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a F PEATH (Mo:, Day, Yr.)
<br />AP-11:$1 22, 2017
<br />28a, REGISTRAR'S SIGNATURE
<br />Last, Suffix)
<br />16a. EMBALMER - SIGNATURE
<br />Katie M. Smvdra
<br />Central Nebraska Cremation Services
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22b. TIME OF INJURY
<br />2e. DESCRIBE HOW INJURY OCCURRED
<br />201707042
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />5a. AGE - Last Birthday 51h. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />92
<br />14a. INFORMANT- NAME
<br />Donna Nelson Wright
<br />CAUSE OF DEATH (See instructions and examples
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITY/TOWN
<br />23b. DATE St1,Ni 0 (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />o z August 25, 2017 12:12 PM
<br />° 123d. To the best of my knowledge, death ocTo the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />0 DQA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Ot
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />1454
<br />STANLEY S. DOOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ® Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />CITY / TOWN
<br />Gibbon
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name
<br />Milford Richard Nelson
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leona Cox
<br />❑ YES 0 NO
<br />❑ Passenger
<br />STATE
<br />g
<br />N
<br />u ce
<br />w 2 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />g p the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />I Jane A. McDonald MD
<br />r g
<br />:a
<br />yes NO PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />nt
<br />Jane A. McDonald, MD, 800 N Alpha Street, 25 TOBA-CO USE CONTRIBUTE TO THE Grand Island, Nebraska, 68803
<br />)6- - ';
<br />6. DATE OF BIRTH (Mo.,
<br />July 15, 1925 ;<
<br />24b. TIME OF DEATH
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />1710794
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 22, 2017
<br />onset tut dee
<br />Pay, Yr <)!
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)::
<br />August 26, 2017
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL ;:.
<br />onset to death
<br />Less Than Week
<br />onset to dea
<br />onset to death
<br />STATE
<br />Nebraska
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 Driver/Operator
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH ?
<br />❑ YES ❑ NO
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />1:114Q
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, yt.)
<br />August 25, 2017
<br />
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