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WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />STATE OF NEBRASKA
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<br />14
<br />DA re OF ISSUANCE
<br />3/9/2023
<br />LINCOLN, NEBRASKA
<br />1
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<br />202306530
<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 -NAME :(First, Middle, Last, Suffix)
<br />Paul Henry Arellano Jr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCiA4'8ECURI7NUMBER
<br />505-66:.82.55
<br />5a. AGE - Last Birthday::
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />211 E 14th Street
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />211 E 14th Street
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUSAT TIME OF DEATH ® Married 0 Never Marled
<br />❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />Ei 11. FATHER'S -NAME {First,. Middle, Last, Suffix)
<br />Paul Henry Arellano Sr
<br />0
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<br />5
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<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) NO
<br />15. METHOD OF DISPOSITION
<br />O Burial ; ❑ Donation
<br />a Cremation ❑•Entombment
<br />❑ Removal ` © Other (Specify)
<br />73.,::.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPfTAL ❑ inpatient
<br />ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 02849
<br />3. DATE OF DEATH (M. o Day, Yr4 .
<br />March 3, 2023
<br />6. DATE QF BIRTH (Mo Day Yr)
<br />February 21:; 1950
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First," Middle, Last,
<br />Donna Michalski
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Aguilar
<br />❑ Hospice Fatflty
<br />9f. ZIP CODE 9g. INSIDE CITY LIMITS.
<br />68801 ®1�Es ❑ No
<br />Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Donna Arellano
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths;Funerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructtens and examples)
<br />5 18. 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 />resoiratory arrest, or ventdculat fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addllonal lines If necessary.
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<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />P.,
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a S I March 3,2023
<br />1 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />S,A March 6, 003 08:07 AM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />al and due id the tause(s) stated. (Signature and Title)
<br />.
<br />E tChad Vieth, MD
<br />a
<br />I
<br />IMMED ATE OAUSE (Fire) MMEDIATE a) Liver Cancer
<br />d
<br />dls�sase "4611
<br />r atnihion res>rnrttg
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list eondiaons, If b)
<br />any, leading to the cause Meted
<br />e'n ane a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNOERb1hNGCAUSE c)
<br />(dice the
<br />e LI
<br />injury that maimed
<br />the events resuhing In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting
<br />Cirrhosis, Hepatitis C, Hypertension
<br />20. IF FEMALE:.
<br />❑:: Not pregnant within past year
<br />❑' PregneM at Vino of ;bath
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a,DATE OF INJURY(Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ,❑ NO
<br />21a. MANNER OF. DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />e underlying cause given In PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Collier/Operator
<br />❑ P.asenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 6, 2023
<br />STATE .;.
<br />Nebraska
<br />17b. Zip; -Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to tleath::.
<br />5 Months . '`
<br />Onset to death
<br />onset to death'
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER GONTACTEDP
<br />❑ YES RI NO
<br />21c. WAS AN AUTOPSY PERFORMED.?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction Site, etc (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />25. DID TOBACCO USE:CONTRIBUTE TO THE DEATH?
<br />121 YES 0 NQ 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />On the basis of examination and/or investigation,in my opinion deaai sopors; at
<br />the 1ime,.date and place and due to the onsets) stated. (Signature and T110e)
<br />26a. HAS ORGAN OR TISSUE DONATION>BEEN CONSIDERED?
<br />❑ YES NO
<br />7. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable 11 28a is NO ❑ YE$ 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 6, 2023
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