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E sir{? bs 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 LEGALDEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 201901948 3/20/2019 LINCOLN, NEBRASKA RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH ANO HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of the dt.ceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kenneth Earl Orr 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 23, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Lewellen, Nebraska (Yrs.) 61 MOS. DAYS HOURS MINS. February 5, 1947 7. SOCIAL SECURITY NUMBER 507-64-7723 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 2 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c, CITY OR TOWN OF DEATH (Include Zip Code) via v.:- - Juov.i I8d. COUNTY OF DEATH 1 Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c, CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1623 W. Koenig St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dianne Hebbard 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clifford Orr 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Donna Mae Beattie 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/14/1966-09/03/1970 14a. INFORMANT -NAME Dianne Orr 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) March 24, 2008 ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 1 f. PART I. Enter thechain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter temllnal events such as cardiac arrest, APPROXIMATE INTERVAL, 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) Gastrointestinal Bleeding disease or condition resulting onset to death < 1 Day jn death} DUE TO, OR AS A CONSEQUENCE OF: ' onset to death Sequentially list condition, if b) any. leading to the cause listed ' on nne a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting m death) DUE TO, OR AS A CONSEQUENCE OF: w5 d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Idiopathic Pulmonary Fibrosis, Idiopathic Thrombocytosis, Diabetes Mellitus 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: ,. 0 Not pregnant within past year ❑Pregnant at time of death❑ 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 0 Not pregnant,'. but pretlnent within 42 days of death ❑ Not pregnant, but pregnant. 43 days to 1 year before death 0 Unknown if pregnant within the past year 0Could SuicideCld': not be determined 9TO 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ©YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE npleted by CERTIFIER VLY 23a. DATE OF DEATH (Mo., Day, Yr.) March 23, 2008 To be completed by CC RONER'S PHYSICIAN c C.COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 24, 2008 23c. TIME OF DEATH 10:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD �3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) • ..r i6... V:.., `.aan 24e. On the basis of examination and/or investigation, in my opinion death occurred atue the time, date and ,lace and dto the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE C EATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 ___. 28a. REGISTRAR'S SIGNATUREjra 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 28, 2008