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<br />THfS .°"COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />TrOi CUMENT BELOW TO BE .A TRUE COPY • OF THE ORIGINAL RECORD
<br />THE ` NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />FF10E, WHICH IS THE LEGAL DEPOSITORy FOR VITAL RECORDS
<br />202306034'
<br />.7 ,,�
<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 />CERTIFICATE OF DEATH
<br />1 DECEDENTS NP.ME First, Middle, Last, Suffix)
<br />Eleanor <F Cline
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Julesburg, Colorado
<br />7. SOCIAL SECURITY NUMBER
<br />608.52-8421
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b, FACILITY -NAME {#f not Instltudon, give street and number)
<br />Grand Island Regional Medical Center
<br />8 ..CITY OR>TOWN Olr: EAATH (Include Zip Code)
<br />Grarld Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />90:STREETANI NUMBER
<br />3208 Kennedy Gh is
<br />9b. COUNTY
<br />Hall
<br />79
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®I Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a.::MARITAt. STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1t FATHER'S NAME (First, Middle, Last, Suffix)
<br />RudolDh ;:Darrel .:Harms
<br />13.. EVER IN ULB. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATHIhte. #ay,r.);
<br />January k1021
<br />6. DATE OF BIRTf((Mo:, Ottii,Wr,) '>
<br />August 22, 194.1 ...,
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />oltpice Ra:d(Iity
<br />rgg. INSIDE CRTY LIMITS
<br />YES' 0 NO
<br />10b. NAMEa 7F SPOUSE (First, Middae, Last, Suffix) If wife, give maiden name
<br />Harold Lenard Cline
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Pearl Campbell
<br />14a. INFORMANT -NAME
<br />Harold Cline
<br />14b, RELATI
<br />Spouse
<br />SHIP TO:D(„CEDENT
<br />16. METHOD OF DISPOSITION
<br />Burial ❑ fionation
<br />Cremat#on ❑ Entombment
<br />Remove#:` Dottier (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (M.o., Day, Yr.),,;,
<br />January 7, 2021:::
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Central Nebraska Cremation Services
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a,FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Al! Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />17b, zjp Coda
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. 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 lines M necessary.
<br />IMMEDIATE CAUSE:
<br />)NIMEDIATE CAUSE {Final
<br />dineaseatcondition requiting>
<br />.... ............:. ...............
<br />In deaths ......:::.
<br />Sequentially list conditions, if
<br />any,leadingto.tt!e cause listed
<br />onhIM a,
<br />Enter the UNi1i;,f0111O GAUGE
<br />(disease or in to that mftiated
<br />LAST
<br />a)COVID 19
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Pneumonia, Respiratory Failure
<br />APPROXIMATE INTERVAL
<br />onsetto doth
<br />72 l'It3t4:
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C):.....
<br />onsetae death::':;;':;
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PANTIE CrTHE#t SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Pancreatic Insufrlciency,Chronic Obstructive Lung Disease, Malnutrition
<br />20. IF FEMALE::.
<br />❑ Nei pregnalltwitalapastyear
<br />Ej Prevantatom ot death
<br />[ Itot pregnant, butpregnant within 42 days of death
<br />0 Not pregnant. but pregnant 43 days tot year before death
<br />E3 Unknown If pregnant within the peat year
<br />220.:, DATE O (NJUI(Y (Moo;, Day, Yr.)
<br />22d. INJURY AT WORK?'
<br />❑ YES D No
<br />21a. MANNER OF DEATH
<br />® Natural D Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />2213. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />19. WAS MEAL EXAMINER
<br />OR CORONER CONTACTED?'
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED? , ..
<br />❑ YES NO•
<br />21d. WERE AUTOPSYYFINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 14
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site; ate. (Spe4ify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221.:LOCATIt7�N..OF #NJUR . STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 4, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />JanuarY.6. 2021
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:41 AM
<br />Atha hest of my knowledge, death occurred at the time, date and place
<br />dl due ratite cause(s) stated. (Signature and Tltle)
<br />nald,.MD
<br />2b. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />d"=.l YES NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2IPOOoa
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e, On the basis of examination and/or investigation, in my opinion dted3 ee4urretl et
<br />the time, date and place and due to the cause(s) stated. (Signature and Tate)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />AME TITL: AND ADDRESS OF CERTIFIER (Type or; Print
<br />ane incl na.k , MD, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />a REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?;:,:
<br />Not Applicable If 26a is NO Y!8
<br />Bio
<br />28b. DATE FILED BY REGISTRAR (180., Day, Yr.)
<br />January 7, 2021
<br />0
<br />c
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