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<br />WHEN THIS COPY (RIES THE RAISED SEAL OF STATE OF NEBRASI(A, iT CERTIFIES THE DOCUMENT BELO
<br />'BEA TRUE COPY1i= THE ORIGINAL RECORD ON FILE Wit THEBIEBRAPVCiPgPARTMENT OF HEALTH AND
<br />•
<br />• HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />STATE OF NEBRASKA
<br />1.15wan+dtdI7I1niIlfs 4imawinfiar w: „„tII61r4ASf4I➢6'IRcr. e , ay*rrrywl!,
<br />DATE OF ISSUANCE
<br />7/5/2024
<br />LINCOLN, NEBRASKA
<br />202403678
<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 />1. DECEDENT S -NAME :(First, Middle, Last, Suffix)
<br />Ste Then; Arthur Whiles
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Denver.;Colorado
<br />7. SOCIAL SECURITY NUMBER
<br />622-68-441 I
<br />Sb. FACiLITY.NAME (If not Institution, give street and number)
<br />1315 Grand island Avenue
<br />8c ::CITY okTowoOPP4Alli (Include Zip Code)
<br />. mind rStand.::68803 •
<br />9a. RESIDENCE -STATE
<br />Nebraska,
<br />thh•STREETAN.D. MUM} ER
<br />;3315 Grand Island Avenue
<br />Db. COUNTY
<br />Hall
<br />55. AGE - Last Birthday
<br />(Yrs.)
<br />76
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />841. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />10ai MARIYAI''STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Monied, but separated ' 0 Widowed 0 Divorced 0 Unknown
<br />1 PATItER'S NAME•(First, Middle, Last, Suffix)
<br />I oul:I .1�35eTrh 1 ►hIles Jr
<br />11 EWER)N UiS A iko FORCES? Give dates of service If Yea.
<br />(Yes, No, or Unk.) No
<br />164ETHOD O WSPO;SITION
<br />Burnes ODofliStion
<br />cr.m*tIon ❑ Entombment
<br />❑ Removal •❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF S` )i :llitrf'>t
<br />Jun 23 2{)4 W.
<br />OTHER 0 Nurng me/LTC
<br />&1 Deceden Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Johlene Ann Bogner
<br />112. MOTHER'S -NAME (First, Middle, Malden
<br />Philomena Ann Sealey
<br />14a. INFORMANT -NAME
<br />Johlene Ann Whiles
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1Ttt:, FIINERAktIciME:NAME AND MAILING ADDRESS (Street, City or Town; State)
<br />Y hEi (SOGCiiy) ..:
<br />18b. LICENSE NO.
<br />• CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused this 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 one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAtJ$E(Fimr a) Abdominal Aortic Aneurysm
<br />dipese or soti¢ritotj eelu5ffl
<br />warmth)
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />Sequential* fist conditions, if b)
<br />amt,' INiUng to;?" cri S : fisted
<br />onSne a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />'EMitr 441114 ERLYINQt'.AUSE d)
<br />(teeose or NIUrythat Wasted
<br />the "Intl' °Suiting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 ;PAlgT ti f,1'1'HER Sj 41PICANT CONDITIONS -Conditions contributing to the death but net re
<br />Cancer, Leuketttia, Emphysema, Parkinson's Disease
<br />20.4F FEMALE .
<br />. Q Net pregnant within pest:ysar •
<br />Ptsgnant 5t tbNo of destti
<br />❑Not pregnant latl' :grant within 42 days of death
<br />Not pregnant, put pregnant 43 days to 1 year before death
<br />Unknoe* itprs9eent:V4thNl the pat year
<br />DATE OFNJURY! (Mo., Des, Yr.)
<br />22d. INJURY AT WORK?
<br />YESyONGi.::::::
<br />21a. MANNER OF DEATH
<br />Natural Q Hdthicide
<br />o Accident 0 Pending)Nvestig tion
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2k.-LOCATIONOF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />SIGNED (Mo., Day, Yr.)
<br />CITYfTOWN
<br />23c. TIME OF DEATH
<br />id Tis tt IH ofidrr Imowtepge, death occurred at the time, date and place
<br />I ntl due to it s tenant.) stated. (Signature and Title)
<br />2L 01D TOBJ Ct.0 55 0ONTRIBUTE TO THE DEATH?
<br />PROBABLY ® UNKNOWN
<br />se
<br />fic, MUNI*
<br />YES•
<br />t:IiYLitotn1
<br />NO;
<br />14b. RELATIONS TO
<br />SPOUSE!
<br />lee. DATE(Mo Day, yrJ
<br />June 25, x'#24 •
<br />;a;EDEkY
<br />n the underlying cause given in PART L 19. WAs.6100 GA1- EXAMI IEIR
<br />OR CORONER Cf i$TACrED?
<br />El YES ONO
<br />21b. IF TRANSPORTATION INJURY
<br />[Driver/operator
<br />::©,Passenger
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY MONO AVAN.A.l e
<br />TO COMPLETE CAUSE OF (MATH?
<br />❑ YES
<br />me, farm, street, factory, office building, construction.uitili Me:(
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />June 25, 2024
<br />240, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 23, 2024
<br />24b. TIME OF DEATH
<br />A011111X. 09.o0 AM.
<br />24& TIME Pig) NOUN pE
<br />toss On the basis of examination and/or Investlgetlon, In•my'epgllon'deU tYAte
<br />ihe>time, date and place end due to the causes) state•t'S61:p'N¢tuu Spit`
<br />•d•
<br />Matthew Alan Works, Deputy Hall County Atter•
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES bij NO
<br />28b. WAS COI
<br />Not Applicable If 28**
<br />21' NAME;'TITI E AND AAUt�ESS OF CERTIFIER (Type or Print
<br />MatthatiWAlan Works, Deputy Hall County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68801
<br />281. REGISTRAR'S SIGNATURE '_•
<br />28b. DATE FILED
<br />June 28, 2024
<br />„ Tr.)
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