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WHENTHIS 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 OFISSUAN+CE2 O 2001018 RUSSELL FOSLER
<br />5/20/2019 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1907518.
<br />CERTIFICATE OF MEATH'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Patsy Ruth Arnold
<br />Female
<br />June 14 2019
<br />. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE -Last Birthday
<br />. UNDER 1 YEAR
<br />Be. UNDER 1 DAY
<br />S. DATE OF BIRTH IMo.,r,Day, Yr,f
<br />tyred
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Eureka Kansas
<br />58
<br />June 20 1960
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />515-58-0859
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Hom*fLTC ( Hospice Facility
<br />fl
<br />[ EWOutpatient ❑ Decedent's Home
<br />ft FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 DOA ❑ Other (specify)
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />9d. COUNTY OF DEATH
<br />xI
<br />Gra11d Island 88803
<br />Hall
<br />_
<br />RESIDENCE=STATE
<br />9 b. COUNTY
<br />9c. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />«
<br />9d. STREET AND NUMBER APT. NO.
<br />9g. INSIDE CITY LIMITS
<br />19f.ZIPCODE
<br />513 Linden Ave
<br />68801
<br />❑ YES ® NO
<br />10s. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Neva► Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nam►
<br />yr
<br />❑ Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Stanley E Amoid
<br />is
<br />11. FATKER'S•NAME (first, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden surname)
<br />I
<br />John William Chilcott
<br />Ruth Marlene Swilly
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service ifYes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, No, or UnkStanley NoE'Arnold
<br />Spouse
<br />16. METHOD OF 01$POSITION
<br />16a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />❑ Buried © Demotion
<br />Not Embalmed
<br />June 18 2019
<br />21 Cremation ❑ Entombment
<br />1:
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal 0 Oth°rt$peclN)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. Stats)
<br />17b. Zip Code
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />88801
<br />CAU§C OF DEATU (See Instru2t[2nsand examples)
<br />IS. PAM 1. Eder the:, attain of eveitta--diseases, injuries, or complications -that directly caused Sha death 00 NOTantertem,inal events such as cardiac arrest, , APPROXIMATE INTERVAL
<br />.r3r
<br />Mpiratory areae,w�vamrfe pr nbAsarian wmMut Mewing the etiology. DO NOT ABBREVIATE. Erato only ane cause an a line. Add additional lines N noceswry. ;
<br />IMMEDIATE CAUSE: ; onset to death
<br />iC
<br />IMMEDIATE CAUSE (Final 41) Esophageal Cancer ; 6 Months
<br />dissese or condition resunmg e
<br />Indenh) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />ieadaMlaliyllatcondeidna,k b)Chronic Immunospression; 7 Years
<br />any, Is"Ing to lM cause listed
<br />d
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE O) Lung Transplant ; 7Yeats
<br />Idle"4e or Injury chit inidimi d
<br />iM seams resulting in tNadtj DUE TO, OR AS A CONSEQUENCE OF: onset to death '
<br />�8T'
<br />d)Scleroderma 20 Years
<br />0
<br />,
<br />A
<br />18. PART 11. 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 N©
<br />0. IF FEMALE:21s.
<br />MANNER OF DEATH
<br />11b, IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED? '
<br />® Not pregnant wkhin past year
<br />Natural ❑ Homicide
<br />❑ Orl"00perster
<br />YES ®NO
<br />P
<br />❑regnant al time of deam
<br />❑ Acalrlem Pending Inwslipation
<br />❑ passenger
<br />21d. WERE AUTOPSY BINDINGS AVAILAeL
<br />Nstproonam, but pregnant within 42 day$ of death
<br />❑ suicide ❑Gould mat W delennlned
<br />© Pedestrian
<br />❑ Nei pregnaM,Lut areguam48 days to 1 year believe Cath
<br />❑ gMr(Sgaky)
<br />TO COMPLETE CAUSE OF DEATH?
<br />.
<br />❑ UeknoyNl if oftoam wlthiti the pest year
<br />❑YES ❑ 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, oto. (specify)
<br />22d. INJURY AT WORK? ':
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />r3YE$ ❑NO
<br />'
<br />rf
<br />r
<br />22f. LOCATION OF INJURY - STREET R NUMBER, APTAO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a, DATE SIGNED (Mo., Day, Yr.) 24b.
<br />TIME OF DEATH
<br />N June 14, 201`9
<br />>
<br />240. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d.
<br />TIME PRONOUNGSD DEAD
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c, TIME OF DEATH
<br />V
<br />$
<br />YJune 14.P
<br />24. On the basis of examination and/or Imsstlgation, in my opinlan death occurred M
<br />This)
<br />v 3d. To the bat of my knowledge, death occurred at the time, dale and place
<br />E
<br />and due to the cau els) stated. (Signature and Title)
<br />Gary Settle, MD
<br />8
<br />the time. Aute and place and due to tM cause(a) stated. (Signature and
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO
<br />Not Applicable If 24s is NO YES ❑ NO
<br />7. NAME, TITLE ANDA DRESS OF CERTIFIER (Type or Print)
<br />Q
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />no. REGISTRAR'S SEGNATURE 2811D.
<br />w�
<br />DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />June 17, 2019
<br />C31
<br />l -A
<br />I
<br />
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