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<br />WHEN THIS `:COPY CARRIES THE RAISED SEALOF 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 A
<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 />Agr2181(4NCE
<br />LINCOLN, NEBRASKA
<br />201907218
<br />led at the time of de
<br />1. DECEDENTS-NAME(First, Middle, Last, Suffix)
<br />Nina Jane Skeen
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 24, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand [stand, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-4633
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />76
<br />Sb. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />ERIOutpatient
<br />0 DOA
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 30, 1943
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑
<br />Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />510E llth Street
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS,
<br />® YES ❑ NO
<br />1.Oa. MARITAL STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />❑:.Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden mune
<br />Rodney Skeen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harold Albee
<br />F 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Husen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yee, N0, or Uttk.) No
<br />15. METHOD OF DISPOSITION
<br />▪ Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other(Specify)
<br />14a. INFORMANT -NAME
<br />Rodney Skeen
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />1$b LICENSE NO.
<br />1191
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr,)
<br />September 28, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aafel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />ie. PART L Enter are sharer events --diseases, iryuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular Bbnllationwithout showing the etiology. DO NOT ABSREVIATE. Enter only one Cause on a lone. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Arrest
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death).:.. __..
<br />seguemlaliy list conditions, If
<br />any, leading to Me cause listed:
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease orinjury.that InMated.
<br />the events
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Blood Clots
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) High Blood Pressure
<br />using m death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant: within. past year
<br />❑ Pregnant at time of death
<br />0 Nat pregnant, but pregnant within 42 days of death
<br />❑
<br />Plot *Plant, but pregnant 43 days to 1 year before Wath
<br />0 ktekeewrt Ii p apnrat within die past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES Q NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Ha,nicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide a Could net be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other(Specily)
<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 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />3d. To the best of my knowledge, Wath occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO ❑ PROBABLY El UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />September 26, 2019
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />September 24, 2019
<br />ZIP CODE'
<br />24b. TIME OF DEATH
<br />08:38 PM
<br />24d. TIME PRONOUNCED DEAD
<br />08:38 PM
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred et
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />Martin Klein, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSuE r e ATION BEEN CONSIDERED?
<br />❑YES i.7 e
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES 0 NO
<br />BY. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />fa
<br />REGISTRAR S SIGNATURE
<br />C. -.L:--
<br />28b. DATE FILED BY REGISTRAR(Mo., Day, Yr.)
<br />October 7, 2019
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