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<br />STATE OF NEBRASKA
<br />)..) 71'VPgat!z, e!riyagomv, °Jd617ii(i pm zymn
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO'.
<br />BE A 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
<br />DATE OF ISSUANCE
<br />4/4/2023
<br />LINCOLN, NEBRASKA
<br />202400248
<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 • F DEAT
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />LeRoy J seph Arends
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCIAL SEcURITY:NUMBER
<br />give street and number)
<br />Fre
<br />P DEATW (klckids Zip Code)
<br />8
<br />RESIDENCE -STATE
<br />Nebraska
<br />9d. ST'REET AND NUMBER
<br />3113W. 16th Street
<br />9b. COUNTY
<br />Hall
<br />Se, AGE - t aet Birthday
<br />(Yrs.)
<br />80
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. 1 DAYS
<br />IIs. PLACE OF DEATH
<br />HOSPITAL t tnpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />1taLalARETAI4TATi s AT TIME OF DEATH Ii] Mauled 0 Never Married
<br />0 Married, but separate! 0 Widowed 0 Divorced 0 Unknown
<br />11 !FATHERS NAME (First, Middle, Last, Suffix)
<br />•• Clarence Arends
<br />/ER IN (IA, ARMED FORCES? Give dates of service if Yes.
<br />s, No, or Unk) NO
<br />18. METHOD OF DISPOSITION
<br />Blutfa I a Donation
<br />o Cremation ©Entotlfbmen#
<br />I Removal :l, [ Other(Specify)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai+
<br />Catherine Sandra Tibbs
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OFrDEAA?H (1
<br />March 30;2023
<br />OTHER 0 Nursing Home/LTC"
<br />❑ Decedent's M
<br />❑ Other(speak)
<br />I Hospice Y ;;
<br />IBd. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />12 MOTHER'S -NAME (First, Middle, Malden
<br />Mavrrie /olkl
<br />14a. INFORMANT -NAME
<br />Catherine Sandra Arends
<br />lea. EMBALMER -SIGNATURE
<br />Todd M Peters
<br />1(1d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />PetersFuneral Hone, 302., Second Street, PO Box 181, St. Paul, Nebraska
<br />is. PAR
<br />teen
<br />Enter the
<br />16b. LICENSE NO.
<br />1078
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />9g. INSIDE crr UM1TS
<br />( YES p No
<br />SIDS)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo„ Day Yr.)
<br />April 4.
<br />;1'Inn. Zip.Cod.
<br />68873€
<br />Nn of events. raseases, Injuries, or complicatlone.hat directly caused the death. DO NOT enter terminal events such as ardlac arrest,
<br />or wereticular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) hypoxia
<br />IMMEDIATE CAUSE f
<br />........................
<br />in d.atbl
<br />Sequentially get conditions.
<br />any,Faadlng to the caup..Magid
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) liver failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sir c) lymphoma
<br />n
<br />ny Ntd
<br />ART IS DT/IEl
<br />20.IF!FEMA :.:.. .._....
<br />Notpregnanlwithin pastyear
<br />Prngnird at time car deaib
<br />NM txo gnont but.pfagtrste wkltin 42 days a death© Not ',replant but pregnant 43 Slays to 1 yw before death
<br />Dunknown f, teetwith n lb. pat year
<br />;;
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />(BMCANTCONDrTIONS-Condition; contributing to the death but nptreauttingln the:
<br />224. INJURY AT WORK?
<br />1:Ives .ONO
<br />s1/0Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural NomIcide
<br />❑ Accident ❑ pendlnp Itiraetigiltion
<br />❑ Sulclds ❑could not be detmnined
<br />22b. TIME OF INJURY
<br />22c. PLACEOF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJUR?l.. STREET R NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 30, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />March 302023 :
<br />F8d To 411. iimii'Airriannviedini, death occurred at the tuns, date and place
<br />4ndi due #a 11014ause(s) stated. (Signature and Title)
<br />Anup V. Sura. MD
<br />23c. TIME OF DEATH
<br />04:27 AM
<br />ndertying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />.471 Onvcrloperator
<br />lPau anger
<br />❑ Pdestn.n
<br />❑ Other (Specify)
<br />tomer Mrm,.
<br />0
<br />19. WAS1NEIMCAi- EXAMINER
<br />OR CORONERCONTACTED?'
<br />❑ vas NQ
<br />21c. WAS AN AUQPIi'
<br />❑ YES I NO
<br />21d WERE AUTOPSYFtNDINGSGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑. NO.
<br />Crest, factory, office building, construction sit
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. 11ME OF DEATH
<br />24d. TIME
<br />24e ton Ma Lesls of examination and/or imratigetlon. In my epinlo n 4.5111 osrb
<br />sla tions, date aro plea and due to the cause(s).ind. (Olgn.tuts ami
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES MI NO U PROBABLY ❑ UNKNOWN ❑ YES gu NO
<br />27' NAME CTS AND:ADDRESS OF CERTIFIER (Type or Print
<br />A€ntip V dura, Mb, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 •
<br />D DEAD.
<br />26b. WAS coasehTGRAI+ITED?.,
<br />Not Applicable if 213a Is NO OYES . ❑.j
<br />a. REGISTRAR'S SIGNATURE
<br />ra ii 6.+.[.un
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 31, 2023
<br />
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