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<br />WHEN ; THIS ` COPY. CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA,
<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 OFISsSUANCE'
<br />10/18/2021
<br />LINCOLN, NEBRASK
<br />SARAHBOHNENKAMPSSISTANT STATE .
<br />A DEPARTMENT OF HEALTH •
<br />REGISTRAR:
<br />AND HUMAN SEI:tVICES .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />£Er1ENTS NAME: {:first;' :Nliddie, ' 1 est, Suffix)
<br />Y1e . Ervin Krtett
<br />4.c►
<br />AND STATE toR.TERRtTORY, OR FOREIGN COUNTRY OF BIRTH
<br />mewNebraska.
<br />7 ;SOCIA•. SECURIT f sompeR
<br />iQ8.124433
<br />b FACILJTY NAME tit' not Institution, give street and number)
<br />Commuriitu Memorial Health Center LTC
<br />CITY OR TOWN OF DEAT1(;
<br />UrWell £x8823
<br />9a. RESIDENCE -STATE:
<br />Nebraska
<br />STREETAID NUMBER
<br />321 KnottAvenue
<br />9b. COUNTY
<br />Hall
<br />1aa,€MARITAL'STATUSATTiMEOF DEATH Married 0 Never Married
<br />'';Married, but separated ;C Widowed 0 Divorced 0 Unknown
<br />FATHER'S NAME•
<br />(Firsf,
<br />Ery ri Everett~ Krro'
<br />Middle, Lest, Suffix)
<br />1s.. EVER IN US ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No,.or unk) Yes: 12/0511942-10/06/1945
<br />•.:METHOD OF:P!SPOSITION
<br />- Bunal 0 Donation :.
<br />CrefnatlOn JEntombment,:
<br />R4r.rro et 0 Other•(Specify)
<br />5a.:AGE - Last Birthday
<br />(Yrs.)
<br />5b."UNbER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY •
<br />MOS.
<br />DAYS
<br />6a. PLACE OF C)EATH
<br />HOSPITAL O;Inpatient
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (M(s;t Day, Yr
<br />September 2021
<br />6. DATE OF B1R4TH:(Mo. bay Yr.I
<br />ER El Nursing Home/LTC
<br />0 ERIOutpatient _. 0 Decedent's Home
<br />0: DOA 0 Other (Spe
<br />I88. COUNTY OF DEATH..:
<br />Garfield
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801,
<br />11)b. NAME OF SPOUSE (First, Middle, Last, Suffix) I/wife,'
<br />Arlene Marie Hurt
<br />l 12 MQMER S -NAME (First, Middle,.
<br />Il Annie Beatrice Bennett
<br />14a. INFORMANT NAME
<br />Arlene Marie Knott
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />:16d. CEMETERY, CREMATORY OR OTHER L0CATtt1N
<br />Westlawn Cemetery
<br />1t1 Faiths; unera(Home 2929 S: Locust Street, Grand Island' Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />IIVStR CITY LIryfITS
<br />les 0 . NO
<br />heti name':'
<br />Malden Surnair
<br />14b. RELATION
<br />"
<br />01.1
<br />16c DATE:(Mo .......,.•
<br />September 30 2021
<br />CAUSE OF DEATH (See Instructions and examples)
<br />15. PART I. Enter tete chain'of events-:.dtaeases, injuries, or complications-thatdirectly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, orventricujarlttbritatton without shoving the etiology. DO NOT ABBREVIATE. Enter only one cause on a ane. Add additional tines if neceseary,
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE tPinal ::::.
<br />q eaa
<br />Nebraska
<br />.•..41.b::ZIpC
<br />17a:<FI NERAL,HC E NAME ANb;MA UNG ADDRESS (Street, City or Town State)•
<br />8):Cardiac Arrest
<br />OIttMATE INTERVAI:':
<br />Sequentiafy.Sst conditions; it.
<br />ay y,:.leedmg to::the C#uae::ksted
<br />•
<br />on:4iie #
<br />EMerSINUS/ itI.YJ(AGCAt3$E
<br />p.(disedse or ittitiry.that iriiNated
<br />ill : the events resulting id death)
<br />Tq - 't.AST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />4)At ri a t Fibrillation
<br />DUE 70, OR AS A CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Hypercholesterotemia
<br />1S' PART Ii HER SIGNIFIG
<br />onsett0 death
<br />Years.
<br />t fio dei
<br />• orteet•to
<br />1 Years
<br />T CONDITIONS'Conditions contributing to the [leath but npj restTti
<br />In tho underlying cause given In PART1.
<br />tti
<br />19: WAS,MEOICAL EXAMINER
<br />OR CORONER.CONTA6TEb2'
<br />.c�.NO
<br />:FEMALE:'
<br />Notpregnantwi
<br />Pregnant af'ttma or d@
<br />of pregnant but frregneni within q2 daya of death
<br />Not pregne(it,'but pregnant 48 dgye to 1 year before death
<br />Unknown:ff,:pragnant w.Ntin Nie past year `
<br />INJURY AT WORK?.
<br />YES :0 NO,..,
<br />21a. MANNER OF DEATH
<br />Natural 0 llonficme
<br />0 Accident D Ponding lnvesttgation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJ
<br />:; DESCRIBE HOW INJURY OCCURRED
<br />2
<br />EET & NUMBER, APT.NO.
<br />23a. DATE OF •DEA7rti (Mo., Day, Yr.)
<br />September 23r 2021
<br />MACROS
<br />2.1b. IF TRANSPORTATION INJURY
<br />:❑ Otiver/Operator,
<br />:Q Passenger - -
<br />•'lO Pedestrian
<br />Other (Specify)
<br />21c. WAS AN AUTDPSY.PERFORMED
<br />YES;
<br />24d WERE AUTOtrSY ttlNDINGSAVAILA'I 1.
<br />:COMPLETE; CAUSE' 0$ DE .11,1 ' . _•
<br />arm,; street, factory, office building,
<br />CIT
<br />23b DATE SIGNED (Mo , Day, Yr.)
<br />.0D} rrib r 24 2021 '
<br />•3d Td. the b4st of. niyknowledge, death occurred at the time, date and place
<br />alit! dui t.O t1t9 rauae(si.stated. (Signature and Title)
<br />H•UCftIR HolmoUi$t,MD -
<br />23c, TIME OF DEATH
<br />12:38 PM
<br />.011] TOBACCO USE,CONTRIBUTE TO THE DEATH?
<br />0 YES ND 0 PROBABLY
<br />UNKNOWN
<br />:NAME; TfTLE AND ADDRESS' OF CERTIFIER (Type or Print
<br />Hugh i~ :loittlqu.iist MD,,410 South 8th Ave`, PO Box 906, Burwell Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME.OF DEA H
<br />247 ,PRONOUNCED DEAD (Mo., Day,`Y
<br />On .the/iasis of examination and/or Ii
<br />:the time, oats and place and due. to
<br />26a. HAS QRGAN..OR TISSUE DONATION BEEN CONSIDERED?
<br />YES jNO
<br />REGISTRAR'S SIGNATURE::
<br />823
<br />28a.
<br />TIME PRONOUNCEDDEA
<br />26b. WAS CONSENT GRA1A
<br />Not Appifeeble if 26a N NO
<br />28b. DATE FILED BY RIEGISTRAR (Mo., Day, Yr.)
<br />October 12, 2021
<br />
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