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<br />:CARRIES THE • RAISED ,.SEAL ?FHE STATE OF NEBRASKA,
<br />CUMENT BELOW TO BE ;A TRUE COPY OF THE ORIGINAL RE
<br />IE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, 'VITA;
<br />HIGH IS THE LEGAL DEPOSITORY FOR ;VITAL.R!ECORDS
<br />202303309`
<br />STANLEY S. D()OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />TATE OF NEBRASKA DEPARTMENT OF HEAL Ft AND I4UMAN SERVICES
<br />CERTIFICATE: OF DEATH
<br />1 DECEDENTS NAMaE
<br />D r ny L Hettgecoc
<br />6/APE Last Bii
<br />lY0) •
<br />64.
<br />S
<br />Ui
<br />iLiTY NAM
<br />/.day
<br />6b. UNDER 1,Y
<br />R
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />M
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0Inpatient
<br />0 t ItYr. t fienl
<br />ODOR
<br />220 US '183
<br />CIT9.OR TOWN
<br />RE'S#DENCE•STATE
<br />NO4raska
<br />.t.tEETr4N0 NUMa,
<br />9 SCtiropder Avent e
<br />ARITAL STATUS AT .TIME OP:tSEATH 511.m 0 Never Married
<br />harried,kut separaWidowed. ; 0 Divorced 0 Unknown
<br />9b, COUNTY
<br />Hall
<br />Sc CITY`!bR TOWN;.
<br />Grand' inland
<br />HOURS
<br />MIN
<br />s. DATE OF DEATh (MO. l ax,Yi
<br />AAni 27;'2,Q17
<br />6. DATE OF' BIRTH(Mei,:Day;Xri
<br />October
<br />OTHER 0 Nursing HomaR.TC !'
<br />0 Decedent'.H."te
<br />bP Other (SpaclfylgosseL;
<br />8d. COUNTY OF DEATH
<br />Harlan
<br />9e. APT. NO.
<br />lob. NAME OFSPOUSE:(First Middle, Last,
<br />Valene Kay. Ar(dereen
<br />EVER tN ti 3.AfgMED FORCES? Givedates of service If Yes.
<br />(Yep to pr UI ) es r ,;10!.05)9 872.10/0411974
<br />9f. ZIP CODE
<br />68803
<br />NO:
<br />affix) if wife, give marl
<br />12. MOTHER'S -NAME (First, Middle, Maiden 8untam
<br />14a. INFORMANT NAME
<br />Valerie Ka tietlgecock
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />DEC
<br />46#f'#LICENSE NO.
<br />Spouse-
<br />pot
<br />pouse DATE'Day V
<br />May 42017
<br />•16d. CEMETERY, -CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />(NERAL H)11E'nHAMEr AND MAILING ADDRESS (Street, City or Town State)::
<br />ten -E uilerMottilarlr Ina:,
<br />501 West Gaae Street. PO Box 185. Blue Hill. Nebraska
<br />RftT I Enter lb
<br />reaP:!!fa ar
<br />CITY/TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See ingtructians and examples)
<br />alp of eve ts: ,diseases;:injirries, or complications- that directly caused the:death DO NOTentertennuhdl everts such as cardiac arrest,
<br />eentricuiaff)tirilltttion without showing the etiology. DO NOT ABBREVIATE Enter only One cause on it gni. Add additional lines If necessary...
<br />IMMAEDiATE CAUSE:
<br />aiHeart'Disease
<br />ATE:CAUSE:(Fine
<br />C' G^RditlOEl'vase
<br />- ;, APPROXIM11ATE'I
<br />Al
<br />DUE.TO, OR AS A CONSEQUENCE OF:
<br />b)`Cardiac Arrest
<br />'onset:
<br />di
<br />OBE TO OR AS A CONSEQUENCE OF:
<br />e UNDERLYINGCAUSE..
<br />r ttr iy#dy:#t#iattdds:s
<br />Sts'renittis .iti;death)...'r.:,.
<br />ENCE OF:
<br />8. PART II.OTHER SII;iNINCA NT'OONDITIONS-Condition s contributing to the death, but not resulting in the underlying cause given in PART I.
<br />AS. NIB n. n i. EXAMINER'. '
<br />GQROME:WcO(NT�CTE@9
<br />If;PrSiYtALE
<br />^� Not pregnant witiitn Past yea' r - ..
<br />3 Premta,tat time of dente
<br />tiro) pret/eaht;;ktet WOW wnhht 42 it of death
<br />Not pregnant y t pr g/iapt 4 days WI TOW before: death
<br />1 Ui It Oiim itrs2egdaatwdhEr thi;Ia#st yiear -
<br />ATE O( INJURY(M*.,Day Yr.)'
<br />21a. MANNER OF DEATH
<br />Natural 0 NeJntaide
<br />0 Accident 0: Pending investigation,
<br />0 Suicide 0 Couldnot be detarntined
<br />-22b. TIME OF INJURY
<br />......... .....
<br />211) tF TRANSPORTA
<br />017ftver/Operator
<br />0 Passenger
<br />DifN.rlestrian..
<br />Q 0*?,:.(Spesify)
<br />ON INJURY
<br />21d. WERE AUTOPSYt°TNDthKSAVAILABLE
<br />TO COMPLETE CAUSE OO) DEATit7
<br />•0 YES LI NO
<br />22c. PLACE OF INJURY -At home, farm, Street, factory, office building, co
<br />Ili Ti ACOf1USI»C.::.INT)aUTE TO THE DEATH?
<br />iY YES 0 NO .: ]PROBABLY.: l UNKNOWN
<br />AME TITL AN r ADDRESS O CERTIFIER (Type or Print
<br />#ryart S : IOQpayjlarlenCountY Attorney, 707 1st Street, PO.;Box 755„ Alma, Nebraska, 68920
<br />t
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEA
<br />MBY 3 2017 eArnx
<br />at... rrt rrl`R 4...44i.1:iJ nit MI %Mo., uay, r r. . 1 cehCi rtiviiv
<br />z 2 2117.
<br />24e. On the basis of examination and/or investigation; Amy dsa
<br />the time, date and place and due to the cause(SI statettiSignehnti.
<br />3yon S.;,MCQuav, Harlan County Attorney
<br />26a. HAS ORf,.ANpR TISSUE DONATTC!t BEEN CONSIDERED? 26b. WAS CONSENT -GRA!
<br />YES NO Not Applicable It 28e la: NO
<br />28b. DATE FILED BY REQ
<br />May 9, 2017 ,:.
<br />
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