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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 4/8/2019 LINCOLN, NEBRASKA 201902209 tr",r RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND IIUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 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. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Arnold DeWayne Frandson 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 27, 2019 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.) ;. Clay Center, Nebraska (Yrs.) 85 MOS. DAYS HOURS MINS. June 10, 1933 7. SOCIAL SECURITY NUMBER 507-48-5997 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility Sb, FACIL ITV -NAME !!f pot Institution, give street and number) Edgewood Vista Grand Island 0 ER/Outpatient ❑ Decedent's Home ❑ DOA E Other (Specify)ASSISTED LIVING 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall dc. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1616 Haqqe Avenue 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑ Married, but separated', ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Connie LaVonne Muirhead 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edmund Frandson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lena Lobeda 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/04/1953-05/05/1955 14a. INFORMANT -NAME Connie LaVonne Frandson 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) March 29, 2019 ® Cremation ❑Entombment Removal :❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 17b. Zip', Code 68801 CAUSE OF DEATH (See instructions and examples) 111PART I. Enter the chain ofevents--diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal 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) Iviulti 6ystem Organ Faiiure disease or condition resulting onset to death Daa'i^o in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Alzheimer Disease any, leading to the cause listed on line a. onset to death Months DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or injury that initiated onset to death the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST a) 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF 'FEMALE: ❑ Not pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? El YES ®NO ❑ Not pregnant, but pregnantwithin 42 days of death ❑Not: pregnant, but pregnant 43 days tot year before death 0 Unknown if pregnant within the past year SuicideCould not be determined ❑TO ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Z2d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a, DATE OF DEATH (Mo., Day, Yr.) March 27, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIMI GF DEA ill 23b. DATE SIGNED (Mo., Day, Yr.) March 29, 2019 23c. TIME OF DEATH 01:00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Chad Vieth, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES E NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO El YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATUREA�^ > ,,rr '�" $"'------r 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 1, 2019