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<br />STATE OF NEBRASKA
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<br />WHEN':: THIS 't'' COPY CARRIES THE • RAISED SFAs pF )lar NATE• 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 />RIciCO IDS DFF/CE, WHICH IS THE LEGAL DEPOSITARY FOR VITAL RECORDS
<br />'DATE OF.ISSUANCE
<br />• 1/31'12020 •
<br />LINCOLN, NEBRASKA
<br />f men ed
<br />202205203`
<br />STATE OF NEBRASKA - DEPARTMENT OF HEAL.
<br />CER FICATE OF bEATH
<br />1. decEDENT'S'NAME ::(first, Middle, Last, Suffix)
<br />Tim Del Hargens
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />AND HUMAN SERVICES
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />�C3rand Island, Nebraska
<br />7. SOCIAL SECURITY: NUMBER
<br />508-86-0265
<br />5a. AGE- Last.Birthday,.
<br />'a 8b. FACIIJTY NAME pfnut Institution, give street and number)
<br />c tF
<br />ttii Health St Francis
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />8a'Pu4CE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC
<br />O ER!Olttpattent 0 Decedent's Hems
<br />0b. F
<br />9a. REStDENCESTATE
<br />Nebraska
<br />9d`STREET AND NUMBER
<br />2916 W. 10th Street
<br />Sb. COUNTY
<br />Hall
<br />10a. MARITAL STATUS; AT TIME OF DEATH ® Married 0 Never Married..
<br />MarrEed; tint aepar4t d 0 Widowed 0 Divorced 0 Unknown
<br />It'FATHER' SI FAME (Pint, Middle,
<br />Delbert Hargens
<br />Suffix).
<br />13. EVER IN U,8., ARME0 FORCES? Give data* of service It ties.
<br />(Yes Nt4 ort111k) NO
<br />IS. METHOD °F DISPOSITION
<br />Burial ❑ .nation
<br />® Cremation 0 Entombment
<br />[Removal.::,. O titter (SPecify)
<br />Sb,.UNDER 1 YEAR
<br />MOS. < : DAYS
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />•
<br />0 Other (Specify)
<br />3. DATE OFDEATN(Ro.,Day, Yr•)
<br />December 10, 2019
<br />(
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />Sc. C#TY Olt TOWN
<br />Grand:Is(and
<br />9e. APT. NO.
<br />M. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />1g, 91$t0E 111te rf$"
<br />® YES 0 NO
<br />,1Ob NAME DF SPQMSE (First,., Middle Last, Suffix) If wife, give maiden
<br />Jo +ce RoJ)ean Whk It
<br />12. MOTHER'S -NAME (F
<br />Beulah Rauert
<br />14a INFORMANT -NAME
<br />JOYce RoJean Hargens
<br />Malden
<br />lea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />14d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17aFUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town,S*Mi)
<br />All Fstiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />1$b. LICENSE O.
<br />CITY ! TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART LEntartheoohs of nts•tlbxses,Injuries,orcrenpaueonsahatdirectly,paidMOdeobtDONOTeatinte nnefirrentssuchascardlesarrest,
<br />respitatgry anent, Or IMAM War fibrillation without showing the etiology. DO NOT AE RREVIATE. Enter only One cause en s ale. Add additenaa lines if necessary.
<br />IMMEDIATE CAUSE:
<br />rramemATE cause (Finest a) Cardiopulmonary Cessation
<br />deem or condition resulting
<br />In death)
<br />91tgWntt iiylldIcQfldxins,Ir
<br />any;.: taadttt6 tophi aaoee listed"
<br />on
<br />Enter the UNDERLYING CAUSE
<br />(dieme:t#,Injarythat iniilatad
<br />the WARMS indeethj ::
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Traumatic Brain Injury
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Cardiac Arrhythmia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18: PART II. OTHER SIGNIFICANT CONDITIONS-Condhions contributing to the death but not resulting In the u
<br />Traumatic $:ubarachnold Hemorrhage, Subdural Hematoma, Intraparenchymal Hemorrhage?;:
<br />20.:IF.FEMALE;J:
<br />O.SM pMenstn vrithte Poet year
<br />0 Pregnant et Ems of death
<br />QpreNot gnan butpargnantwlthtn 42 days of death
<br />Not pre9naS4 but pregnant 43 day. a4I year before death
<br />rr�'## unknown if*regnant wiitin the pest year
<br />22*. DATE OF INJURY Oho., Day, Yr.)
<br />Unknown.
<br />22d. INJURY AT max?i > >.
<br />® YEs ,0 NO
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />E Accident 0 Pending Anel
<br />0 Stoic de Cobitl Sot hetia4Ofifln
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF I
<br />Unknown
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />FALL
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />Unkrtown.
<br />3?ATE....TH (Mo., Day, Yr.)
<br />December 10, 2019
<br />.sDATE SIGNED (Mo., Day, Yr.)
<br />December 31. 2019
<br />URY-At h
<br />ly
<br />In PART I.
<br />2'ib, IF TRANSPORTATION INJURY
<br />'❑ tlrtveddpaator
<br />0 Passenger
<br />i]jE Pedestrlen
<br />Q Othar(Specify}
<br />r, street,
<br />Rame)
<br />i+d1 RE ATIGNsi tP TG DErEDeNT
<br />leo. DATE (974. Dep, Yr)
<br />December 12.2019
<br />APPR Ariimam
<br />sent td 11NAth
<br />Hours
<br />V
<br />onset to death
<br />Years
<br />oneett:*daatit
<br />1L WAS MEG/CAL EXAMINER
<br />OR CQR:OONTACTD?
<br />0'POW
<br />ND
<br />21c. WAS AN AUTOPSY PERFORMED/
<br />0 YES El NO
<br />Sid. WERE AUTOPSY FINDING$ AYR11-4 s
<br />TO COMPLETE CAUSE OF DEATH
<br />OYES no
<br />e building, co
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />03:13 AM
<br />ed. To the bat of my knowledge, death occurred a the time, date and place
<br />and due to the cauaps) crated. (Signature and Tai)
<br />,Joshua R Anderson, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YESNO .. 0 PROBABLY 0 UNKNOWN
<br />27. NAME,TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Joshua Flt: Anderson, MD, 908 N Howard Ave, Ste 108, Grand (stand; Nebraska,68803
<br />28*. REGISTRAR'S SIGNATURE..�-
<br />STATE
<br />Nebraska
<br />34a OATESIGNED.(Mo., Day, Yr.)
<br />OUNCED DEAD (Mo., Day, Yr.'
<br />ZIP CODE
<br />lAtf. TtffAlt OF tiEA'Ii1
<br />24t TIME PRONOVii t CEDIilA;1} "
<br />24e. On the basis of examination ander MeasegWon. I Mg Opinion death,seurred at
<br />the time, date and place and due to the caua(a) abated. (Slenaarw and had
<br />26a. HAS ORGAN OR TISSUE DONAt1
<br />DYES ] NO
<br />CONSIDERED?
<br />Amentled.
<br />11Sl20211 Amended; Item 7 508-86-2229 To 508-88-0265
<br />26b. WAS CONSENT GlIANTES
<br />Not Applicable If Mrs NO 0 YES
<br />28b. DATE FILED BY REGISTRAR:#Mott DAY . Yr
<br />December 31, 2019
<br />N
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