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<br />STATE OF NEBRASKA
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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 />9/30/2021
<br />LINCOLN, NEBRASKA
<br />202109207
<br />tlG...id
<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 />CERTI
<br />21 12491
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are flied with the county court in the county where the decedent resided at the time of death. , I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Allan Rudolph Andreasen
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />September 17, 2021
<br />4. CITY AND STATE OR, TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5e. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., bay, Yr.)
<br />Hastings, Nebraska
<br />(Yrs.)
<br />79
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 18, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-6701
<br />8a. PLACE OF DEATH
<br />HOSPITAL--® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b.<FACILITYNAME (If not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN
<br />Grand Island
<br />OF DEATH (Include Zip Code)
<br />68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9dSTREET AND NUMBER
<br />214 W. 14th Street '
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS'':
<br />12 YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Arlene May Liske
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Lawrence ; Andreasen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elsie Murrish
<br />13., EVER IN U,S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Arlene May Andreasen
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />0 Burial ❑ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />September 19, 2021
<br />EJ Cremation OEntambment
<br />Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801<.
<br />CAUSE OF DEATH (See instructions and examples)
<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 />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Plnai a) Respiratory failure
<br />disease or condition resulting :-
<br />onset to death
<br />Days
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Pneumonia
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />Days
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Emu the UNDERLYING CAUSE c)COVID-19 infection
<br />(disease Or Injury thatingiated
<br />onset to death
<br />Days
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART H. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Atrial fibrillation
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20.1F FEMALE:
<br />0 Not prognant within past year
<br />0 Pregnant attune of death i
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑::Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown ifpregnant within the past year
<br />Suicide Could not be determined
<br />❑ ❑
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY'.RNDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />_
<br />22a, DATE OFINJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site; etc. {Specify)
<br />22d. INJURY AT WORK?
<br />DYES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 17, 2021
<br />To be completed by
<br />CORONER'S: PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH`
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 17, 2021
<br />23c. TIME OF DEATH
<br />02:55 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best ofhema:Ceknowledgestated , death occurredand at theTitltime, date and place :
<br />atjit due tb iuse(s) (Signaturee)
<br />Scott Heasty, MD
<br />24e. On the basis of examination and/or Investigation, in my opinion death OCcured at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Scott Heasty, MD, 2300 S 16th, Lincoln, Nebraska,
<br />68502
<br />28a. REGISTRAR'S SIGNATURE7
<br />�G4-4a.-16 8 /Lewri,L� rrc
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 22, 2021
<br />
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