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<br />STATE OF NEBRASKA
<br />ih Dbo ;...T94ihtlf!„<.kiiSa 400NhhI
<br />HI+N t tS Ct PY CARRIES THE`RAISED SEAL OF STATE OF NEBRASIt4, tT CERTIFIES THE DOCUMENT BELOW T
<br />A T'AU,E COPYOF iE ORIGJN,4L. RECORD ON FILE WITH T .E NEBRASKA DEPARTMENT OF HEALTH AND
<br />MAtii SERVICES, "*AL. RECORDSOFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OF ISSUANCE •
<br />5124t022
<br />LINCOLN, ' NEBR;ASKA:
<br />imende
<br />202204499
<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 OECEDENT:S-NAME (F4rs( : ,Middle, . Last, Suffix)
<br />C#lfford Atthur• Arnold
<br />CiTYANo STATE OR TERRITORY,' OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska:.
<br />SOCIAL SECURITY .NUMBER `
<br />50744-2410
<br />6a AGE - Last Birthday
<br />(Yrs.)
<br />91;
<br />FACILITY -NAME tff trot Iffstitution; give street and number)
<br />CHE Health Good"Semaritan
<br />Sc :;C:ITY DR TOWN Ol DEATH;
<br />Kearney 58848
<br />9a. REStDENCE=BTATE
<br />Nebrsska:.
<br />BTRSETAND NUMBER:.`"
<br />1411 Staperoach Rd
<br />ludo Zip Code)
<br />9b. COUNTY
<br />Hall
<br />-5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSSPI TAL I Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />Ida TiIARtTAL STATUS ATTIME,01 DEATH fJ Married 0 Never Married
<br />Married,:b taepaiated ❑Widowed ❑Divorced 0 Unknown
<br />11,.'FgTHER S.,bAME',(Fr
<br />hied Arnold•
<br />Last, Suffix)
<br />U.4 ARMED.FORCES7 .Give.dates of service if Yes.
<br />of tank )1YeS: 10!03/1950-10/03/1954
<br />17a:PONE .
<br />All �'aittls;
<br />9c. CITY OR TOWN
<br />Grand Island
<br />1013: NAME :OF"SPOUSE (First;
<br />Bonnie Breiner
<br />14a. INFORMANT -NAME
<br />Bonnie Arnold
<br />ISa.EMBALMER-SIGNATURE
<br />Not:Embalmed
<br />I8d. COUNTY OF DEATH
<br />Buffalo
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH:046. Day Yr:.
<br />April 13, 21)22
<br />8. DATE OF BiRTH<(ISo, Day+.Yi
<br />OTHER 0 Nursing Home/LTC:
<br />•
<br />0 Decedent's Home
<br />❑ Other(Speclfy)
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9(0 l.�INJlpE•
<br />1
<br />14Y) T19$.
<br />Middle, Last, Suffix) If wife, give maidenftame
<br />12. MOTHER'S -NAME (First, Middle,
<br />Margaret ;! Filter
<br />fed. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Central Nebraska Cremation Services
<br />GME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />neral Gomel 2929 S..t.ocust Street, Grand Island ;Nebraska ::
<br />18. PAt1 t l: Enter tibi C sin -0
<br />r0epirat0y erreet; tN.yb
<br />CAUSE OF DEATH `(See'instruction
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />idMtTS:'
<br />14b. RELATlO
<br />Wife
<br />leo: DATE'(Mo.,
<br />April.14,. q!
<br />1181g.
<br />rid examples)
<br />•
<br />Ms diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />War fibrillation without showing the etiology. DO NOT ABSREVIATR, Enter only one cause on a line. Add additional tines if necessary.
<br />JMMEDIATE: CAUSE:
<br />Septic Shock
<br />uentiaay the:0nditions
<br />**Width(' to fli capee:I
<br />an;tlaaa
<br />.>OIiE'TC); ORAS A CONSEQUENCE OF:
<br />i)ACute hypoxic Respiratory Failure
<br />Etiiei.'lha UNf�#{iltwaCAl!
<br />.(dlue¢1tai» lit ify.. irki'FtaY1
<br />ManintMa resulting In death
<br />DUE TO,.OR AS A CONSEQUENCE OF:
<br />c)Aspiration Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Mvanced Dementia
<br />•11VPART iI ?0114 1451
<br />ONOITIONS-CorldiUons contributing to thetieath 0
<br />3..IF: FEMALEi
<br />Not pregn'.:
<br />pregna3pt; but pregnantwlthin'.42 days of death'
<br />t preghardi.but pregnant:O days to f year before death
<br />Unknown ifpregnentwitlilnthe•pastyear
<br />22a.:DATE OF ItJ
<br />22d.-INJURYAT•
<br />WORK?:.
<br />' ❑YES :.:Z7NQ:.`
<br />URY(Mo-
<br />y, Yr
<br />21a. MANNER QF.DEATH
<br />Ea Natural Q Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />tsuiting ;r1 the t fderiying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b... IF. TRANSPORTATION INJURY
<br />tairinVer/Operator
<br />I..! Paaaahger
<br />Q Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMItNER:•
<br />Oa'.CrQRONEI " SNTACTED?..
<br />® YEs. `.: Q NO. ;;
<br />21d WERE AUTOPSY MONIS AVAlLASLE
<br />TocoMPLefe CAUSE'OF DEATH?
<br />❑'YES [ NO
<br />22c. PLACE OF INJURY.At home, farm, street, factory, office buildings construction site,
<br />22e: DESCRIBE HOW INJURY OCCURRED
<br />CATION; OF INJURY :=STREET &NUMBER, APT.NO. CITY/TOM
<br />23a, PATE OF DEATH (Mo., Day, Yr.)
<br />April 13, 2022
<br />244 DATE SIGNED (Mo,, Day,.Yr.)_ 23c. TIME OF DEATH
<br />ACTH 1f 2022 •02:17 AM
<br />36Toting best df my itnowledge, death occurred at the time, date and place
<br />and; dua td tits causes) stated:(Signature and Tide)
<br />Lissa A Woodruff MD ..•
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />P:C0DE
<br />24b. TIME 010 DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />240. Onthe basis of examination andfor Investigation, in my oginttmtien.deatff oaceffred6E
<br />tate time✓Hate and place and due to the cause(s).stated, (Signssad "viae}•
<br />8 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES IEl NO
<br />N./ME,'HTL AND! ADDRESS OF CERTIFIER (Type or Print
<br />Lassa A. woodruf#;:MD,�10 E 31st St., PO Box 1990, Kearney,>Nebraska, 68847
<br />DID TOBAGG,O USE.CONTRIBUTE TO THE DEATH?
<br />•YES ❑ Nti ❑ PROBABLY it UNKNOWN
<br />28a. REG(STRAR'S.SIONATURE
<br />5/24/2022 :: (tem 7, 507-24.2
<br />0 `Yo 507-24-2410
<br />28b. WAS CONSENTGRANTED
<br />Not Applicable if 28e Is NO
<br />L1
<br />28b. DATE FILED BY REGISTRAR (Mo., R
<br />April 20, 2022
<br />
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