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STATE OF NEBRASKA
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<br />WHEIII'THt$ COPYCARIES THE RAISED SEAL OF STATE OFNEBRASKA, IT atOriFiEs THE DOCUMENT BELOW TO
<br />B E A ]."RUE 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 />DME:OF ISS.(JAfifCE
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<br />4/19/ Q24'
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<br />2 0 2 4 0 3 6 8 DEPARTMENT OF EALASSISTANT STATE TH
<br />R
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />ERTIFICATE OF DEATH
<br />1: DECEDEN.3'8-NAME ;:(First, Middle, Last, Suffix)
<br />'Clarence Daryl:: Baxter
<br />C
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7:8044 sECURITYNUMBER
<br />;507448.5883
<br />Bit, FA(2U111 AME (If not Inetitution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c ;C11 Y ONTOWN OF;L)EATH (Include Zip Code)
<br />Grand 10400 466803
<br />Bf RESIOEr-8TATE
<br />Nebraska
<br />8d:: STR£ET ,AND NUMBER
<br />3166m:MoitoOt # clad
<br />Sb. COUNTY
<br />Hall
<br />Sa._AGE I,;ti#t;8lydtdl
<br />(Yrs.)
<br />90
<br />BS, UNDER1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE of DEATH i M
<br />Ap)'it-9, 2624
<br />6. DATE OF BIR7t Y (Mon Day; Yr.) .
<br />Mai/ 14,..1.933...
<br />$si'P1 ACE OF DEATH::.:.
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Hanw/LTC
<br />0 ER/Outpatlent 0 Decedent's Home
<br />❑ Other (Specify)
<br />❑DOA
<br />18e INARITAI STATtlS:AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated J WIdowed 0 Divorced 0 Unknown
<br />11FATHERS-NAME (First, .Middle, Last, Suffix)
<br />Clarence:' George:; Baxter
<br />13:: EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yee, No, or Unit.) Yes 06/15/1953-05/11/1955
<br />15. METHOD OF DISPOSITION
<br />Q Bta dei Oceesdon
<br />Cremation t»rA Entoiribment
<br />Removal . ©other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />tOb. NAME:OF SPOUSE
<br />Sallie Sundeen
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />313
<br />Sf. ZIP CODE
<br />68803
<br />pica FiticililY
<br />sg alw(
<br />® YES
<br />rat, Middle, Last, Suffix) If wife, give maiden M
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elsie Alexander
<br />14a IN0ORMANT NAME
<br />Scott Baxter
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />17a. FUNERAL HOME NAME AND MA LINO ADDRESS (Street, City or Town, State)
<br />,bvingstot'D SOndarmann Funeral Home, 601 N. Webb Road, Grand Island Nebraska;<;am.
<br />CAUSE OF DEATH ($f.;instrti'ctiorls and examples)
<br />is. PART I. Erderthe chain of events- diseases, injuries, or complications -that directly cauted the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular flbrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if naceesary.
<br />IMMEDIATE CAUSE:
<br />MMSD A7s CAUSE (Finer; . a) Vascular dementia
<br />ryknsae orton reaud8;>
<br />kt•
<br />•
<br />de.
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />onakm a
<br />(Melina; or In jury tha J tlfled
<br />Its events rosuitlr. g in death)
<br />thj
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />183 PARTY OTHERSIO NPICl/tsT CONDITIONS -Conditions contributing to the death but not re
<br />Prostate c.arlper paraz)/sinal atrial fibrillation
<br />20.1E FEMALE:
<br />tttx Pregilsilt within Priet yen
<br />Pmdean$ilttimSt *.i
<br />MotprgfMAt tit ptkt!it nt within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to year before death
<br />❑ Unknown n pregnantwithin the past year
<br />2*:DATE INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK/
<br />❑YES ONO
<br />21a. MANNER OF DEATH
<br />® Natural O Honfucide
<br />❑ Accident Peeling investlyatbn
<br />0 Suicide LJ Couid not be determined
<br />Z2b. TIME OF INJURY
<br />21b,, IF TRANSPORTATION INJURY
<br />❑ DfIva/Openaor
<br />© Passenger
<br />O Pedestnan
<br />0 Other (Specify)
<br />MKS
<br />1411 RELATIONSHIP TO DECEDENT
<br />son
<br />164. DATE (Mo., Day, Yr.) . .
<br />April 16.4:004
<br />. STATE
<br />• Nebraska.
<br />17b.:t13. a
<br />68803 :.
<br />APPROXIMATE INTERVAL
<br />Omit
<br />Years
<br />onset to deal
<br />is. WAS.t?1.OA1 E,34AMINEN
<br />ort COR€ NERCONTA D?
<br />YES { Nq .
<br />21c. WAS AN AUTOPSY PEPD?
<br />❑ YES ®NO
<br />Underlying cause given In PART L
<br />21d. WERE AUTOPSY [llf+►DtNGS AVAILA E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ ves . Q Na.:..
<br />22c. PLACE OF INJURY-Athome, farm, Street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f ;LOCA4TIt7N OF INJURY,. STREET & NUMBER, APT.NO.
<br />23a DATE`OtDEATH (Mo., Day, Yr.)
<br />April 9 2024
<br />23b, DATE SIGNED (Mo., Day, Yr.)
<br />Ab/'il 11 2024
<br />CITYROWN
<br />23c. TIME OF DEATH
<br />03:57 PM
<br />.1 G 0 'fo the twst.army knowledge,'
<br />occurred at the time date and pace
<br />s ear Si,:due to thercewe(s) stated. (Signature and Title)
<br />1 Steven Husen, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Ste;
<br />r)
<br />24b. TIME OF DEATH`
<br />,ZIPP0DE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e Qn thtt blue of examination and/or investigation, in my opinion deaf:cc'
<br />the limb, data and place and due to the causes) stated. (swnaairaOkell le)-
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DO. ATION BEEN CONSIDERED?
<br />YES• ❑ NO ::❑ PROBABLY ® UNKNOWN 0 YES !7
<br />27 M 1TR.E MID ADDRESS OF CERTIFIER (Type or Print
<br />Steven Htisen; lti, 2116 W Faidley #400, Box 9802, Grand Itland„.Nebralika, 8803
<br />28a. REGISTRAR'S SIGNATURE
<br />A
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if Mils NO ❑ YES
<br />� I0
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 15, 2024
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