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?`t STATE OF NEBRASKA Am* Lif at 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 OP ISSUANCE 2/14/2017 LINCOLN, NEBRASKA 2018037 04 CApii STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Arthur Richard Langvardt 4,:CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Junction City, Kansas 7. SOCIAL SECURITY NUMBER 511 -44 -0794 8b. FACILITY -NAME (Knot Institution, give street and number) 43 Sonja Drive 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 43 Sonja Drive 10a. 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 tlnk.) Yes ' 1971 -1973 1 5. METHOD OF;DISPOSIT)ON ®`Burial ❑ Donation El Cremation ❑ Entombment ❑ 0 Other (Specify) 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death Not pregnant,, but pregnant 43 days to 1 year before death ❑ unknown if pregnant wittertthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) r 2d. INJURY ATWORK? • ❑ YES ❑ NO 25. DID TOBACCO USECONTRIBUTE TO THE DEATH? a YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE • Last Birthday (Yrs.) 73 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined a 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH • t El February 9, 2017 12:30 PM • 0 t2 3d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) re 234. DATE OF DEATH (Mo., Day, Yr.) February 8, 2017 Ryan Ramaekers, MD 28a. fi£GISTRAR'S SIGNATURE 13- avow"- 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH(Mo., Day, Yr.) February 8, 2017 6. DATE OF BIRTH (Mo:,: Day, Yr.). January 24, 1944 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient 0 DOA OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Doniphan 9e. APT. NO. 9f. ZIP CODE 68832 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Teresa Luther 11. FATHER'S -NAME {First, Middle, Last, Suffix) Arthur L Langvardt 1' 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Eunice J Wiley 14a. INFORMANT -NAME Teresa Luther 8d. COUNTY OF DEATH Hall 18b. LICENSE NO. 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) February 9, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION BV Cremation Center CITY / TOWN Hastings STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Butler- Volland Funeral Home. 1225 N. Elm. Hastings. Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chafe 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 cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Lung Cancer Metastatic disease or condition resulting .. in death) APPROXIMATE IN TE RVA L onset to.death 6 Months` $eriuentially conditions, if any, leading to the Cause fisted on line a. DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE Cr) ( disease or injury initiated onset to death the events resultifl9 in death) IA$t DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ ❑ Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY. PERFORMED? `! ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 N 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 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 24b. TIME OF DEATH 24d. TIME PRONQUNCEDDEAD 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 Tide) 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (190,, Day, Yr.) February 13, 2017