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STATE OF NEBRASKA
<br />111/1
<br />r°. o
<br />WHEN i THIS `COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />•
<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 /S THE LEGAL DEPOSITORY.FOR VITAL RECORDS
<br />r lei 62 i,"
<br />DATE OF ISSUANCE
<br />8/20/2020
<br />LINCOLN, NEBRASKA
<br />202202203
<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 />Arlene Theresa Kramer
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lindsay, Nebraska
<br />T. E3CJAL SECURITY NUMBER
<br />505.52 402.1
<br />8b. FACILITY-NAME•flfiiot Institution, give street and number)
<br />CHI Health St. .Francis
<br />8c. CETY QR TQwNN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9d, STREET AND NUMBR
<br />3345 North US Highway 281
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.) ....
<br />77
<br />NDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® ER/Ou patient
<br />0 DOA
<br />10a.49ARITAL STATUS.AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 10699
<br />3. DATE OF DEATH (Mo., Day Yr,:)
<br />Aup.ust 1142020
<br />6. DATE OF BIRTH (ho., Day, Yr)
<br />March 14,;1943 .
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />osplce Facility
<br />8g: INSIDE CITY L(MITS'
<br />❑ YES ® NO:f:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name •
<br />LeRoy Kramer
<br />11 FATHER'S -NAME (First, Middle, Last, Suffix)
<br />lithriStt lllDbhMari
<br />12 MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Ann :Theresa Braun
<br />13. EVER IN 0.5. ARMED'FORCES? Give dates of service if Yes.
<br />(Yes,'No, or Unit.) No
<br />15. METHOD OF DISPOSITION
<br />VS>Burtal ❑ Ddndtion
<br />•
<br />Crerttat)on ❑ Entottlbment
<br />❑ Removal nattier (Specify)
<br />14a. INFORMANT -NAME
<br />LeRoy Kramer
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHE
<br />Westlawn Cemetery
<br />R LOCATION
<br />17a.FUNERAL:.HOM.E;NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />14b. RELATIONSHIP
<br />Husband
<br />16c. DATE
<br />August 1p 2020 ;'
<br />Grand Island Nebraska
<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 />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 (Floal a) Unknown Natural Causes
<br />disease ott;onditlhn r68atti58
<br />death)
<br />Sequentlally list conditions, if
<br />any, leading to, the, cause, listed
<br />8,18 :188 UNDERLYING GAUGE
<br />(disea'se.:or In/ury:that initiated
<br />the events resulting in death)
<br />LAST
<br />17b. Zip,Code.....
<br />iDEN`r ::
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cardiogenic Shock
<br />onset to death -"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Acute Hypoxemic Respiratory Failure
<br />onset'/o..death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTR,ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but notreaUltingi the underlying cause given in PART I.
<br />Enlarged Heart, Chronic Anemia, Pulmonary Hypertension, Hypothyroidism
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE'
<br />Nre
<br />btpgeamwithin past year
<br />© Pregnant attime of death
<br />❑ INot pregnant,' but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />unknown d pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />21b.. IF TRANSPORTATION INJURY
<br />Dover/Operator
<br />Passenger
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®: NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑,:,NO
<br />22a,'DATE OF IN IU
<br />22d. INJURY AT WORK?
<br />(M:
<br />❑ YES ,,.❑NO
<br />Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PEACE pF INJURY•At home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY::? STREET & NUMBER, APT.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />rm, street, factory, office building, construction site, etc
<br />23c. TIME OF DEATH
<br />TOttie best of ntij:knowledge, death occurred at the time, date and place
<br />andOue tothe::tause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 12, 2020
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />,August 11, 2020
<br />24b. TIME OF DEATH'
<br />09:52 PM
<br />24d. TIME PRONOUNCED DEAD
<br />09:52 PM
<br />240.04 the basis of examination and/or investigation, in my opinion death Othttrred'iat
<br />the time; date and place and due to the cause(s) stated. (Signature and Ttle)
<br />Christopher J Harroun, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION . BEEN CONSIDERED?
<br />❑ YES ❑:NO
<br />26b. WAS CONSENT GRANTED? ::.
<br />Not Applicable if 26a is NO ❑ YES ' ❑ No
<br />2700ME TITLE'AND AQDRESS OF CERTIFIER (Type or Print
<br />C'hrstophe.r J Flatroun, Hall County Attorney, 231 S Locust St, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE 3
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 17, 2020
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