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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
<br />11/30/2020
<br />LINCOLN, NEBRASKA
<br />202010073
<br />7
<br />SARAH BOHNENKAMP
<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 />20 16361
<br />E
<br />5
<br />4C
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dale Albert Whitefoot
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH-(Mo.,Day,
<br />November.l.9,2020'
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Boelus, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-48-5515
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Kearney Regional Medical Center
<br />95
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL '® Inpatient
<br />o ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH(Mo., Day,Yr.)
<br />May 24, 1925
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code) 8d. COUNTY OF DEATH
<br />Kearney 68845 Buffalo
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />17464 W Old Military Road
<br />9b. COUNTY
<br />Buffalo
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated Ea Widowed ❑ Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Shelton
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68876
<br />9g INSIDE CITY LIMITS
<br />© YES Citi NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Jeanne Catherine Stubblefield
<br />11. FAT'HER'S.NAME (First, Middle, Last, Suffix) 12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Albert P Whitefoot Lillie F Bernhagen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 03/06/1951-02/20/1953
<br />14a. INFORMANT -NAME
<br />Brent Whitefoot
<br />14b. RELATIONSHIP TODECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />®'Burial ❑Donation
<br />0 Cremation ❑Entombment
<br />0 Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Dennis Harrahill
<br />16b. LICENSE NO.
<br />1330
<br />16c. DATE (Mo., Day, Yr.)
<br />December 5, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Shelton Cemetery Shelton
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfe) Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examDles)
<br />18. PART I. Enter the chain of events- .diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a) COVID-19 Pneumonia
<br />IMMEDIATE CAUSE (Finan
<br />dinease Or Condition resulting
<br />in deamj
<br />Sequentially list conditions, If
<br />any, leading to the, cages : lifted
<br />on line a
<br />Enter the UNDEttYIN(8 CAUSE
<br />(disease or injurythat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)COVID-19
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />17b. Zip: Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />10 Days
<br />onset to death
<br />2 Weeks
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />16. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Obstructive Pulmonary Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />40. IF FEMALE:
<br />Q Not pregnant within post year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown tf pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑Passenger
<br />❑'Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY:FINDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />LE
<br />224.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, etc. (Spec(fy)
<br />22d. INJURY AT WORK?
<br />Q YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 19, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 20, 2020
<br />23c. TIME OF DEATH
<br />02:10 PM
<br />230.70 the batt of my knowledge, death occurred at the time, date and place
<br />and dye t0 the cause(s) stated. (Signature and TRH)
<br />Kristin R. Lawson, MD
<br />26. DIDyTOBACCO USE CONTRIBUTE TO THE DEATH?
<br />LJ YES � NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADbRESS OF CERTIFIER (Type or Print
<br />Kristin R. Lawson, MD, 816 22nd Ave., Suite 100, Kearney, Nebraska, 68845
<br />z
<br />11E'
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />P CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.y
<br />24d. TIME PRONOUNCED DEAD
<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 cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES [i]NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES
<br />❑)HO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., D
<br />November 24, 2020
<br />ay, Yr.)1
<br />0)
<br />0
<br />CO
<br />C'
<br />
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