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<br />WHEN i 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 />8/23/2021
<br />LINCOLN, NEBRASKA
<br />dl
<br />202110490
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Clifford Eugene I Armstrong
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-38-1966
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Bb. FACILITY -NAME IR not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />4305 Quail Lane
<br />9b. COUNTY
<br />Hall
<br />85
<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 El Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 10482
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />August 9, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 20, 1935
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />105.4 MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Bess Rogene Olsen
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix)
<br />Clifford Armstrong
<br />12. MOTHER'S -NAME (First,
<br />Naomi Hudson
<br />Middle, Maiden Surname)
<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 />Bess Rogene Armstrong
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />IS. METHOD OF DISPOSITION
<br />0 Burial ODonation
<br />El Cremation ❑Entombment
<br />Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.),
<br />August 11, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />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 />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or comptications4hat 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAINE (Final ?: a) Respiratory failure
<br />due's,. er condition resulting
<br />in dauh)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />• online a.
<br />Enter the UNDERL:YfNtt CAUSE
<br />(disease or Injury that initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) congestive heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) chronic obstructive pulmonary disease
<br />17b. Zip Code
<br />6881/1:
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />8/44/2:17:8/9/21
<br />onset to death
<br />8/4/21 - 8/9/21
<br />onset to death
<br />8/4/21 -8/9/21;
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />protein-ca€orie malnutrition
<br />20. IF FEMALE:
<br />0 Not pi'egnafltwtthln past year
<br />Pregnant at time of death
<br />❑ :Hot pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f. LOCATION OF
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />-ice} Accident 0 Pendlne Investigation :.
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ElNO
<br />21d. WERE AUTOPSY FININGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑NO_
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />URY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 9, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 11 2021
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />10:40 PM
<br />3d. To the beet of My knowledge, death occurred at the time, date and place
<br />and dos to the tause(s) stated. (Signature and Title)
<br />Jose Baio, APRN
<br />25. DID TOBACCO USE. CONTRIBUTE TO THE DEATH?
<br />0 YES IE NO 0 PROBABLY 0 UNKNOWN
<br />27,: NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jose Bajo, APRN, 3533 Prairieview, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP COD
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death OClurrAi et
<br />the time, date and place and due to the cause(*) stated. (SignaturettnClitte)
<br />26a. HAS ORGAN OR TISSUE DONATION ATION BEEN CONSIDERED?
<br />OYES i7 e
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES
<br />0 N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 12, 2021
<br />
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