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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
<br />DATE OF ISSUANCE
<br />2/12/2018
<br />LINCOLN, NEBRASKA
<br />201801579
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTI-i:AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS - NAME (First, Middle, Last, Suffix)
<br />Rodney James Clark
<br />4. CITYIAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -64 -8294
<br />$b. FACILITY -NAME (If got Institution, give street and number)
<br />4212 West US Highway 30
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<br />Nebraska
<br />LL 9d. STREET AND NUMBER
<br />▪ 4212 West US Highway 30
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<br />E
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER IN U,S, ARMED :FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />15. METHOD QF DISPOSITION
<br />❑ Burial ❑ Donation
<br />E Cremation ❑ Entombment
<br />❑Removal s❑ Other .:(Specify)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c )
<br />(disease et injury that initiated
<br />the events resetting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
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<br />... _. ._. d)
<br />s U,
<br />1
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<br />A
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />0
<br />'A 2d, INJURY AT WORK? ..:
<br />0
<br />OYES LI NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />8a. REGISTRAR'S SIGNATURE
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />72
<br />MOS.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE NOW INJURY OCCURRED
<br />5b. UNDER 1 YEAR
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803.
<br />.t3 Caetzei+-
<br />DAYS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />1:4 19a. RESIDENCE -STATE
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® ER/Outnatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />E Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />i9e. APT. NO. 1 9f. ZIP CODE
<br />1 68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Linda May Purdie
<br />11. FATHER'S -NAME {First, Middle, Last, Suffix)
<br />Cecil George Clark
<br />12, MOTHER'S -NAME (First,
<br />Lena Fines
<br />Middle, Maiden Surname)
<br />14a. INFORMANT -NAME
<br />Linda May Clark
<br />16b. LICENSE NO.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 3, 2018
<br />6. DATE OF BI
<br />December 13. 1945
<br />H (M a., Day, Yr.)
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo„ Day, Yr)
<br />February 5, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter me chain of events- -diseases, injuries, or complications -that directly caused they death. DO NOT enter terminal events such as cardiac arrest,
<br />fflspiratdty arrest, or ventri ular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Lung Cancer
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Months
<br />in death / :;:.
<br />Seguem,ally list Cord bons, 13
<br />any, leading to the Cause listed
<br />onime
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />:IVES ? NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Nnt pregnant, but pregnant within 42 days of death
<br />• 0 Not pregnant butpregnant>43 days to 1 year before death
<br />❑ 1lnknown dpregnant witfan the past year
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 S:;icide ❑ Could not be determined
<br />21b.IFTRANSPORTATION INJURY
<br />❑' Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other IC/pacify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITY /TOWN STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 3, 2018
<br />23b. PATE SIGNED (Mo., Day, Yr.)
<br />February 5, 2018
<br />23c. TIME OF DEATH
<br />08:30 AM
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />® YES ❑ NO ❑PROBABLY ❑UNKNOWN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?' 26b. WAS CONSENT GRANTED?
<br />❑ YES E NO Not Applicable if 26a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR(Mo., Day,
<br />February 8, 2018
<br />
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