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<br />(\ STATE OF NEBRASKA�
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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />'EEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN:SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSl14NCE
<br />4/2120 2:
<br />LINCOLN, NEBRASKA
<br />1 ReOEDENT'S NAME {First, Mi
<br />Ctlff©rd...Ar' huf Arnold'
<br />20220338
<br />.
<br />f�I
<br />SARAH BOHNENKAMP f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES;
<br />TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />le, Last, Suffix)
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />T. SOCIAL SEctJRITYNUMBER
<br />807-242910
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAIVE tit not Institution, give street and number)
<br />CHI Health Good Samaritan
<br />Bc,.CITY OR INN OPDEATH (Include Zip Code)
<br />Kearney 88848
<br />9a. RESIDENCE$TATE
<br />Nebraska
<br />Ed. ,$:TREET AND NUM EER:
<br />111 Staltecc5Ch Rd
<br />1Da <'MARITAL<$TATUSAT'TIME
<br />Married, but separated
<br />11 FATHERS-P(AME;FIret, Middle,
<br />Ned Arnold
<br />9b. COUNTY
<br />Hall
<br />H IE Married ` 0 Never Married
<br />d 0 Divorced 0 Unknown
<br />Last,
<br />Suffix)
<br />13. EVER IN U:S ARMED::FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) Yes 10/03/1950-10/03/1954
<br />15. METHOD OF DISPOSITION
<br />[;',1:004i41
<br />QDonat4on
<br />:,Cremation ❑Entombment
<br />QIRemoval ❑Other (Specify)
<br />91
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE QP DEATH
<br />HOSPITAL..® Inpatient
<br />ERJOu patient
<br />❑ DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Buffalo
<br />HOURS
<br />MINS.
<br />22 05820
<br />3. DATE O, F DF.t TH..O. O yr Yr );
<br />Apd(1, X22
<br />6. DATE OF IMRTH (Mo., ba)/At:) •
<br />October 1': t:
<br />OTHER 0 Nursing HemBI .TC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />95. APT. NO.
<br />1(1b. NAME pF SPOUSE (First, Middle,
<br />Breiner
<br />12. MOTHER'S -NAME (First,
<br />Mareatet .: Filter
<br />Bonnie
<br />14a. INFORMANT --NAME
<br />Bonnie Arnold
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE
<br />68801
<br />Last, Suffix) If wife, gll
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.'FUNERAL.HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All 1=aiths:Funeral Home, 2929.6. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />Middle, Mahan
<br />CITY I TOWN
<br />Gibbon
<br />maiden
<br />14b RELATION414 TQ titaMIN i
<br />Wife
<br />16c. DATE (Mo, Day. Yr )
<br />April 14, 2022
<br />)raska
<br />CAUSE OF DEATH (See illsti ucttenS a.nd examples)
<br />13. PART I. Enter the chaln'of events-dfeaeaes Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ven�icular abdliation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.',
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(Final a) Septic Shock
<br />disease of tonetten resulting:::
<br />in dltethl DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)Acute hypoxic Respiratory Failure
<br />any, leading to the cause limed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />ErdertneuNDLti(iYiNGCA+1s C)Aspiration Pneumonia
<br />(disease or inluy:tttat initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Advanced Dementia
<br />18. l ARTA OTHER SIGNIFICANT CONDITIONS-CondlUons contributing to the death but not resultIng In the underlying cause given In PART I.
<br />2Q. iF FEMALE,;,
<br />Not yfegnent withtrr peat yea
<br />O Pregnant et time M aeetlt
<br />❑ Not pregnaltt nut pragnarit itt 42 de.
<br />0 Not pregnant, but pregnant 43 days to yeer before. death
<br />..❑ Unknown It pregnant within the past year
<br />2a OATE•OF.tNJURY (MO., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NQ.
<br />21a. MANNER OF DEATH
<br />Natural ❑ Npmlalde
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />© Dr4ver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />Days
<br />Death
<br />onset ttt:death
<br />ofllAtto deaYs
<br />Years
<br />19. WAS MEDICALE XAMINER
<br />OR G 1#:CO AOTSD? €
<br />21e. WAS'-
<br />❑YES
<br />21d. WERE.
<br />TO CO
<br />0 YRS
<br />SYuTOP,F1r Hvs`A
<br />22c. PLACE OF INJURY -At hore,;farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />IyOCATIONOF INJURY:: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 13, 2022
<br />23b. DATE SIGNED (Mo., Day,
<br />Abrin 14 1I?2
<br />234,
<br />-row bbst of g y knowietipe;
<br />stttk due tM the:Ceuseisi 514111
<br />Lissa A. Woodruff, MO
<br />ra
<br />23c. TIME OF DEATH
<br />02:17 AM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ccurred at the time, dateand place
<br />am and Title)
<br />24b. nM
<br />24d. TIME
<br />On the•basis: of examination and/or investigation, kt my+
<br />the time, date and place and due to the cause(s) stated.
<br />26a. HAS ORGAN pit TISSUE DONATION SEEN CONSIDERED?
<br />NAMErTETtE`ANI ADD❑YES • NO
<br />27.
<br />EES OF CERTIFIER (Type or Print
<br />LiSSB A. Woodruff, MD, 10 E 31st St., PO Box 1990, Kearney,' Nebraska, 68847'
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO PROBABLY ® UNKNOWN
<br />28a. REGISTRAR'S SIGNATURE
<br />ci
<br />26b. WAS CONSENT
<br />Not Applicable if 26a Is fN
<br />28b. DATE FILED BY RE (Mo Day Yr I•
<br />April 20, 2022
<br />01
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