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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 f
<br />F2019 0 0 3 ,� t RUSSELL
<br />y 3 ASSISTANT STATEE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />12/28/2018
<br />LINCOLN, NEBRASKA
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Archie Edward Armstrong
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 11, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.) _.
<br />Horton, Kansas
<br />(Yrs.)
<br />93
<br />MOS,
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 26, 1916
<br />7. SOCIAL SECURITY NUMBER
<br />511-18-7062
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER E Nursing Home/LTC ❑ Hospice Facility
<br />813, FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Veterans Home
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1919 W. Oklahoma Av
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT. TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Elizabeth Fitzgearld
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Samuel Armstrong
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Emma Sibenmorgan
<br />1$. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes :'12/15/1942-12/13/1945
<br />14a. INFORMANT -NAME
<br />Elizabeth Armstrong
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />E Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Mo., Day, Yr.)
<br />January 16, 2010
<br />❑ Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />St. Peter And Paul Cemetery Seneca Kansas
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St.. Grand Island. Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL.
<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)Alzheimers Dementia
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />in deatn)
<br />-:. DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if i b)
<br />any, leading to the cause fisted
<br />onset to death
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disea86 of injury that initiated'^.
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<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 />❑ YES ENO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ENO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Notpregnant,:but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ El
<br />Suicide Could not be determined
<br />❑
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />0YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />T
<br />be
<br />leted
<br />E IC LCERTIFIER J
<br />MEDICAL CERTIFIER 111
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 11, 2010
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 12, 2010
<br />23c. TIME OF DEATH
<br />09:15 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />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 />Jennifer King, MD
<br />240. 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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer King, MD, 2300 West Capital Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 16- /�iJKi
<br />v
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 13, 2010
<br />CD
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