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<br />WHEN ;THIS COPY CARRIES THE RAISED SEAL OF THE STATE 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
<br />RECORDS OFFICE, WHICH IS THE LEGA
<br />DATE OF ISSUANCE
<br />10/18/2021
<br />LINCOLN, NEBRASKA
<br />E
<br />xs
<br />A
<br />0.
<br />1. DECEDENTS -NAME (First, Middle,
<br />Lyle Ervin Knott
<br />HUMAN SERVICES, VITAL
<br />L DEPOSITORY FOR VITAL RECORDS
<br />Cti Is 42_
<br />t+h'tlit.I,f.ft*
<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 />Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE 0RTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney,: Nebraska
<br />5 ;AGE - Las(Birthday Sb. UNDER 1 YEAR
<br />ars.)
<br />7 .SOCIAL SECURITYWtdMBER
<br />608-12-7433 •
<br />8b. FACILITY -NAME (1f not Institution, give stree and number)
<br />CornmurlitY Memorial Health Center LTC
<br />8c. CITY OR TOWN OF'DEATH (Include Zip Code)
<br />BUr :: ll 68823
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />99<:
<br />MOS.
<br />80, PLACE OF DEATH
<br />HOSPITAL ❑ inpatient OTHER El Nursing H
<br />ER/Outpatient 0 Decedent s'11
<br />DAYS
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH: (Mo, Aay, Yr.):.
<br />September 2S, 2021
<br />6., DATE OF atRTh.{Mo., Day, Yr.)
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Other (Specify);
<br />I8d. COUNTY OF DEATH
<br />Garfield
<br />9d. STREET ARO NUMBER8g INSIDE CITY LIAi1I7 S
<br />321 Knott Avenue YES CI. NO
<br />10a. MARITALMarried Never Married .STATUS AT TIME OF DEATH #
<br />® ❑ .10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />Arlene Marie Hurt
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />11 FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ervin Everett Knott
<br />112. MOTHER'S -NAME (First, Middle,
<br />Annie Beatrice Bennett
<br />Maiden Surname)
<br />13.EWER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 12/05/1942-10/06/1945
<br />14a. INFORMANT -NAME
<br />Arlene Marie Knott
<br />14b. RELATIONSHIP TO.DECEDENT
<br />Spouse
<br />18. METHOD OF DISPOSITION
<br />„121Burial 0 Donation
<br />] Cremetlon ❑ Entombment
<br />0 Removal ` 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17s. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Fatths Funeral Home 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />16c. DATE (Mo., Day, Yr)
<br />September 30, 2021
<br />CAUSE OF DEATH (See Instruct+
<br />s and examples)
<br />STATE
<br />Nebraska
<br />djb ZlpCode
<br />68801:
<br />14. 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 Ones if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a). Cardiac Arrest
<br />disease or conaitton restd(ing
<br />In death)
<br />Sequentially list conditions, If
<br />any,>Ieeding to the ceuse:bstdd
<br />en>Ibte a ..
<br />Enter the UNDERLYV4G CAUSE
<br />(disease or hijtttyi.that itttttSted
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Atriai Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Hypercholesterolemia
<br />18. (PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the -underlying cause given in PART I.
<br />20 IF FEMALE,:,,,
<br />U Ndt}ae9natit wi8tin psatyear
<br />Pr$gtlant et tlma of dkath:-
<br />❑:<idtit pregttatit, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if,pregnant Within the past. year
<br />22e OATS() JURY (Ma:, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ;❑ NO
<br />22r LOCATN
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />El Accident Pel(dinglnvestigetiort
<br />0 Suicide ElCould not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />..❑ Passenger
<br /><'❑ Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />; Years
<br />onsettodeath
<br />Yeaf(it
<br />onset to death
<br />Yeats
<br />19. WAS MEAIC/(L EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES RI NO
<br />21d. WERE AUTOPSY FINDINGSAVAIUI E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES
<br />22c. PLACE OFINJURY.At home farm, street, factory,; office bulldog, construct(
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 23, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 24, 2021
<br />23c. TIME OF DEATH
<br />12:38 PM
<br />ad. To:the bast sin* knowledge, death occurred at the time, date and place
<br />>snd due:te ti s'cause(s) stated. (Signature and Title)
<br />Hugh R. Holmquist, MD
<br />U K
<br />a
<br />�
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />$49.:On thcDasis of examination andfor investigation, In my opinion death occurmil at
<br />the time, date and place and due to Bre causes) stated. (Signatere Hent Tdie) :
<br />25..DID TOBACCO USE. CONTRIBUTE TO THE DEATH?
<br />Q YES ::;❑ NO j,] PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ANO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO
<br />27, NAM$, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />ugfl R. Holmquist, MD, 410 South 8th Ave., PO Box 906, Burwell, Nebraska, 68823
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 12, 2021
<br />J
<br />
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