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<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
<br />DATE OF ISSUANCE 201906891,
<br />1/7/2019
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lyle Dwight Klinginsmith
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />North Loup, Nebraska
<br />$ 7. SOCIAL SECURITY NUMBER
<br />A
<br />v 505-48-6718
<br />0
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not (Institution, give street and number)
<br />Good Samaritan Society -St. John's
<br />d
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 68847
<br />9a. RESIDENCE -STATE 9b<COUNTY
<br />1 Nebraska Hall
<br />9d. STREET AND NUMBER
<br />. 1716 North Lafayette
<br />90
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 24, 2018
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 10, 1928
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Buffalo
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITYIJMITS
<br />® YES ❑ NO
<br />1
<br />Oa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />e 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Maxwell Klinqinsmith
<br />10b. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name
<br />Ina Elaine' Olsen
<br />112. MOTHER'S -NAME (First, Middle,
<br />Bessie Gabaurer
<br />Maiden Surname)
<br />z. 13. EVER IN U.& ARMED FORCES? Give dates of service if Yes.
<br />(Yes No or Unit.) S Ye 03/28/1952-03/17/1954
<br />o.
<br />15. METHOD OF'DISPOSITION
<br />g ® Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />c0 Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Ina Elaine Klinginsmith
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />January 2, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mount Hope Cemetery
<br />O 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY / TOWN
<br />Scotia
<br />CAUSE OF DEATH (See instructions and examples)
<br />§ 14. PART 1< Enter tlq Chain -of events -.diseases, injuries, or complications -that directly causae the dealt, 130 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrant, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one causeon a lire. Add additional lines it necessary.
<br />/ IMMEDIATE CAUSE:
<br />F. IMMEDIATE CAUSE (Final a) Heart Failure
<br />e disease or condition resulting
<br />in death)
<br />%.tt1 8arruentially list cOnditiotls,
<br />any, leadky to the <ausa)feud'
<br />on line a.
<br />5 .Enter the UNDERLYING CAUSE
<br />p • ;diseaseorfnjuryhatirutiated
<br />•
<br />d
<br />the events resetting in death)
<br />LAST.
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />b)
<br />STATE
<br />Nebraska
<br />17b, 2 Code
<br />68801
<br />APPROXIMATE IN)rERV
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />5 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART!.
<br />2 Congestive Heart Failure, Diabetes, Atrial Fibrillation Hypertension
<br />1q
<br />tg r 0. IF FEMALE:
<br />E
<br />0 Not pregnant within past year
<br />.0
<br />{{VG 0 Pregnant at time of death
<br />i3 ❑ Not pregnant 'but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />g ❑ unknown it pregnant wHnin the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />Ot ef(Specify)
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO.
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO J
<br />w 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />'Cl DYES ONO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />v 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />N
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />t 1 December 2a, 2018
<br />i t 23h. DATE wailed iMo.. Day. Yr.) 1 23c. TIME OF DEATH
<br />I il 1 December 31, 2018 1 05:15 PM
<br />q 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />G and due to the cause(s) stated. (Signature and Title)
<br />Jenna N, (;)err, MD
<br />CITY/TOWN
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD ..
<br />24e. On the basis of examination and/or Investigation. in my opinion death occuned at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title),
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />26b. WAS CONSENT GRANTED? Ir
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print-
<br />26a.
<br />rint
<br />Jenna N. Derr, MD, 3320 Ave A, Kearney, Neb aska, 68845
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo. Day, Yr.)''
<br />January 4, 2019
<br />W
<br />01
<br />U3
<br />
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