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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; WIitCHIS THE LEGAL DEPOSITORY:FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />10/18/202.1'
<br />LINCOLN; NEBRASKA •
<br />02301565
<br />1y�r �/'""� t fir_
<br />SARAH BOHNENKAMP p`
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1...;F}ECEDERT`S-N rME ;thirst;
<br />Lylertrin Krtett .
<br />Middle, Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITY AND $TATe t R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />• 0
<br />d.
<br />•E•
<br />• le
<br />O
<br />4;
<br />Kearneu;:.Nebreska •
<br />? `:SOCIA SECURITY NUMBER'
<br />608g124:4334!..
<br />8b; FACIL)TY-NAME(lf'not Institution, give street and number)
<br />Community Memorial Health Center LTC
<br />ac CiTYORTCRwNOi peATH(IncludeZipCode)
<br />•
<br />Burwell 58823
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />9d STREET AMD NUMBER
<br />321 Knott Aveflue ,
<br />9b. COUNTY
<br />Hall
<br />8a„AGE • Last:•Birt
<br />(Yrs.)
<br />y 5b: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />3': DATE OF"DEATH. (Mo Day Yr.)
<br />September 23, 2021..,. -,
<br />6. DATE OF.BIRTk1(Mo , DayYr )
<br />MOS.
<br />DAYS
<br />6a. PLACE OF DEATH
<br />HOSPITAL ❑trapatt8nt
<br />❑ ER/Outpatient
<br />❑:DOA
<br />lOa MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />[I'.Married, but separated : 0 Widowed 0 Divorced ❑ Unknown
<br />11 FATHERS NAME IFrrit .
<br />Ervin Everett Krtott.
<br />Middle; . Last, Suffix)
<br />13EVER IN U S. ARMED FORCES? Give dates of service if Yes.
<br />(Yss, No, or Unk.i Yes ::.1.2/05/1942-10/06/1945
<br />15. METHOD:OF DISPOSITION::` . '
<br />Burial ❑ Donation
<br />O Cremation ❑ Entombment --
<br />Removet• ❑ Otfier (Specify) :
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.:
<br />April 16,;.1922
<br />I8d. COUNTY OF DEATH
<br />Garfield
<br />9e. APT. NO.
<br />1513. NAME OF SPOUSE (First, Middle, Last
<br />Arlene Marie Hurt
<br />14a. INFORMANT -NAME
<br />Arlene Marie Knott
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />14;:.:FUNERAL F1oME NAME AND MA UNG ADDRESS (Street, City or Town; State)
<br />All Earths Funeral Home,.2929 S. Locust Street, Grand Island, Nebraska.•
<br />9f. ZIP CODE
<br />68801
<br />8g I SIDEti1TYLIMIT
<br />® YES•Q Nt3
<br />Suffix)`If wife; give maiden name'.
<br />12.MOTHER'S-NAME (First, Middle,
<br />Annie Beatrice Bennett
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT:
<br />- Spouse
<br />18c. DATE (Mo , o4.0,4•:••••
<br />Septan er 3fi x2021
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART 1. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as' cardiac arrest,
<br />respirato�iy arrest, or ventricular fibrillation without"showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a 11ne. Add additional Tines if neces
<br />IMMEDIATE CAUSE:
<br />a) Cardiac Arrest
<br />IMMEDIATE CAUSE IPiaal .
<br />disease orcon4*sort itteu1t1!Is'
<br />• •
<br />..Sequentially fist condittone, if...
<br />arty,,leading to ttte cause listed
<br />hrdeatht:.
<br />Eider the:yiNDERLYEO CAtNSt SE
<br />(disease or irdtirythat idittated
<br />the.events resuhing in death)
<br />18 :PART Id OTti
<br />20. IF..FEMALE::.'
<br />©-'.Nei pregnant wdhrn peak:year
<br />•Pregnant at time of death:
<br />❑: Ietrtpregnant bm pregnant within 4t.days of death
<br />Not pregnant, but pregnant 43 days to 1 yearbefore death
<br />Q:r,Unitnown dfpregnant within the past year
<br />IG
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b3Afrial Fibrillation
<br />DUE TO, OR AS A'CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />4) Hypercholesterolemia
<br />sTA7E
<br />Nebraska.
<br />17b:i.P:Code:r
<br />68801:;
<br />'APPROXIMATE INTERVAL
<br />•
<br />onset to death
<br />Minutes .. `
<br />CANT CONDITIONS -Conditions contributing to thedeath
<br />22a DATE OPNJURY (Ma Day Yr_)
<br />22d. INJURY AT WORK?
<br />D YES.:.::!;NO,.:... `.
<br />r#.:LOCATIi
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />0 Accident © Pehdmglnveshgatton
<br />❑ Suicide ❑ Could not be determined
<br />t net ret uRing in the underlying cause given in PART!.
<br />2211. TIME OF INJURY
<br />22c. PLACE OF INJURYY At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />N4URY: STREET S NUMBER, APT.NO.
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />September 23, 2021
<br />CITYrrOWN
<br />23b.:DATE SIGNED:(Mo., D:ay, Yr.)
<br />SeptetnE3er 24,'2021
<br />23c. TIME OF DEATH
<br />12:38 PM
<br />td Tothe bast df nw knowledge, death: occurred at the time, date and place ::
<br />e!Sfl duetOthe'oausels) stated. (Signature and Title)
<br />Hugh R. Holmquist, *MD.
<br />25.0).0..:.TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ,❑ NO ❑PROBABLY121 UNKNOWN
<br />§o
<br />ph. IF TRANSPORTATION
<br />❑ 17!tdvertOperator
<br />•:❑ Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />onset:to dead-'.
<br />Years
<br />19: WAS Mfg DIOAL'EtfAMINER
<br />OR:COROkle R .CONTAC'TE D?
<br />216. WAS AN AUTOPSY PERFORMED?
<br />OYES NQ
<br />•
<br />214.•WERE AUTOPSY FINDINGS AVAILABLE
<br />.`'TO COMPLETECAUSE OFDEATH?''
<br />❑. YEs • ❑ NO
<br />me, farm, street, factory, office building,'construction site;: e
<br />(Bo
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.
<br />OF DEATH
<br />ODE
<br />244. TIME PRNOUNCED DEA. .
<br />$4Onthe basis of examination andtor investigatign,.in my'optnrondaath oocu(iwdat' :
<br />';the tlple, date and place and due to the ceueelsjstaled ISignatureaad itle)<
<br />26a. HAS ORGAN, OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27,:NAME4 TIT*<E AND ADDRESS'OF CERTIFIER (Type or Print
<br />Huzgh R tiolhicidist MI3, 410 South 8th Ave., PO Box 906, Burwell, Nebraska 58823
<br />28a. REGISTRAR'S SIGNATURE
<br />16-1a_17
<br />28b. WAS CONSENT
<br />Not Applicable if 26a is NO, 0 YES, .Ij
<br />28b. DATE FILED BY REM STRAR:(Mo,, Day, Yr.).
<br />October 12 2021•
<br />
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