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Its f SAM ( t0`' Jaw .Vt.Ln 11ii `i A...ddd ?. \w, it AIM kna, �.� i.....eH.. , s a..er e.k STATE OF NEBRASKA 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 11/20/2017 LINCOLN,. NEBRASKA 201803762 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) Archie Clyde Ogg LL 4, CITYANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cozad, Nebraska 7. SOCIAL SECURITY NUMBER 521 -26 -8714 tr 2 U b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center ce 8c. CITY OR TOWN OF DEATH (include Zip Code) p Grand Island 68803 9a. RESIDENCE -STATE Nebraska • 9d. STREET AND NUMBER • 1512 W Anna Street .0 A+ Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, but separated:: ❑ Widowed ❑ Divorced ❑ Unknown a 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes No, or unit.) Yes ;03/25/1943 - 01/05/1946 40 15. METHOD OF DISPOSITION F ❑ Burial -❑ Donation ® Cremation ❑ Entombment ❑ Removal :❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska in death) 'Sequentially list cot any, leading to the c on line a. Enter the UNDERLYING CAUSE tiiiseeseo(iniury lint initiatedi:: the events resblting:In death) LAST 11. FATHER`S - NAME (First, Middle, Last, Suffix) Archie Clyde Oqq Sr 1s, PART I. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest, respiratory arrest, or vetdrieular 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) Hypoxic Respiratory Failure disease or condition resulting 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Transitioned To Hospice Care 20. IF FEMALE; ❑ Not pregnam within bast year ❑; Pregnant at time of death ❑ Not pregnant;tlut ptegnantwithin 42 days of death ❑ etbt pregnant, but pregnant 43 days to 1 year before death ❑ Iknknown it pregnadt within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY ATWORlt? YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a, DATE OF DEATH (Mo., Day, Yr.) Nov 13, 2017 23b. DATE SIGNED (Mo., Day, Yr.) November 13, 2017 DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Prostate Cancer DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c, TIME OF DEATH 06:06 AM a re iii _1 g u G 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) Michael A. Danner, MD 25. DID TOBACOO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN �28a1 17£GISTRAR.'S SIGNATURE 5a. AGE - Last Birthday (Yrs.) 93 9b. COUNTY Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION Trinity United Methodist Columbarium 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 510 UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN. Grand Island 16a. EMBALMER-SIGNATURE Katie M. Smvdra DAYS HOURS ad. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY 12. MOTHER'S -NAME (First, Middle, Bertha Amos Marshall March 14, 1924'` OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jessie Lorraine Vanosdall 14a. INFORMANT-NAME Jessie Lorraine OAR 16b. LICENSE NO. 1454 CITY / TOWN Grand Island CAUSE OF DEATH (See instructions and examples) MINS. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) November 13, 2017 6. DATE OF BIRTH (Mo., Day, Yr.);; Maiden Surname) 9g. INSIDE CITY LIMITS ® YES ❑ NO 1411, RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) November 17, 2017 STATE Nel)raaka 17b, Zip Code 68801 APPROXIMATE INTERVAL onset to death Immeidate onset to death Years onset to death onset to ❑ Hospice Facility 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED'? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO { 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Danner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the causeis) stated, (Signature and Title) 24b. TIME OF DEATH ZIP CODE 24d. TIME PRONOUNC DEAD 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 14, 2017 26b. WAS CONSENT GRANTED'? Not Applicable if 26a is NO ❑ YES ❑ NO