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STATE QF NEBRASKA
<br />rrrrrMAt@a;i .Rttt491. ' fit 71mat9th!.MRPr, oyAmtlif? "AWAWN
<br />WHEN HIS COPYCCA. ONES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EISA TRUE COPY OPITHE 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 />OATE0r1S5 4NCE
<br />8/21/2024
<br />LINCOLN, NEBRASKA
<br />202404243
<br />304
<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,i0ECEDENT*FIANIE `(beat, Middle, Last, Suffix)
<br />darty Bene M1lter.
<br />4. CITY AND BTATE'OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dortiohart 'Nebraska
<br />00clAL SECURIiYNUMOER
<br />808-44-8474
<br />2. SEX
<br />Male
<br />3. DATE OF DEATI1(M0.xD y,?Y i
<br />November 28; 2018
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (if not institution, give street and number)
<br />Grand isla0d:Veterans. Home
<br />8a, CITY;:O*% TaWN<OF DEATH (include Zip Code)
<br />fraud isird 68803
<br />II 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d:;$TREET AND NUMBER
<br />.2300 Weet<Capttal Ave
<br />9b. COUNTY
<br />Hall
<br />78
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />D,DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS MINS.
<br />6. DATE OF SIRTH (Mo., Day;'Yr.)
<br />August 18 1940
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />8a.4142tTAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Hospice Faculty
<br />99 t.N IDE CItY lmftYI
<br />J'YE8 ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name`
<br />Karen Ray Arp
<br />11 FATHER8NAME (Fhat Middle, Last, Suffix)
<br />DY Mliter
<br />E 12. MOTHER'S.NAME (First, Middle, Maiden Surname)
<br />11 Evelyn Meinecke
<br />13. EVER IN U S: ARMED FORCES? Give dates of service if Yes.
<br />g (Yes, No, of Unk.) Yes 08/12/1958-08/17/1961
<br />0
<br />"' 16..M..E1 . OD OF;PISPQSI.1. O
<br />Bur}tt {Donation
<br />'* ,(:orarnattetR ❑EntombmNent
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Karen Kay Miller
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services Gibbon
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />17a. 0N.P.RA L HOMENAME AND MAILING ADDRESS (Street, City or Town, State)
<br />,1111 Faithsulral Home, 2929 S. Locust Street, Grand Island,; Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />iS. PART 1. Enter tai chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter termini events such as cardiac arrest,
<br />.,, respiratory aneet, prventdouW fibrillation without snowing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(!inat ' a/Cerebral Infarction
<br />dbs as er aonw..... rat+UlN+Eti
<br />dead)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />rs
<br />Sequentially tot conditiorro If b) Arteriosclerosis
<br />any . gwdtraq to dte sanas sated
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Eti rtheONDSS YMGCAU Cl.
<br />(disease or injury that initiated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18;P4RT it OFMER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting
<br />Atrial Flbriffatlon, Hypertension
<br />IP<FEli1ALE:
<br />Notptatgdtuutyltbl(!(rast year
<br />P s9n.ntinlitrer?nsa►h
<br />Not Iare9Oent, but pregnant within 42 days of death
<br />❑ •Not prapnept, but pregnant 43 days to i year before death
<br />i.`."..i<UnItn m3fj i 9!.l,.I�il thine,* past y ar
<br />wQ 22a;DATEOPJNJWIYIMo::.Day, Yr.)
<br />tai
<br />d.iNJURYATWORK? .
<br />88.0 040.1 040.1 Obs pF Like. STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />in theunderlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />APedestrian
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At home;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />November 28, 2018
<br />CITY/TOWN
<br />bb DATE SIGNED (Mo., Day, Yr.)
<br />Ft3vvM 1 8.2018
<br />td.TA tllR bias ydttiy knowted9s, death occurred at the time, date and place
<br />du/ t¢t t..Cause(s) Mated. (Signature and Title)
<br />Cinda K. Ritchie, APRN
<br />23c. TIME OF DEATH
<br />09:03 AM
<br />To coo
<br />YSS
<br />14b. RELATIONSHIP TO
<br />Spouse
<br />16c. DATE (MMa, 011.• Yr,)
<br />Novembet:.: 0:201:8
<br />EDEN?:
<br />TATE..*!.
<br />Nebraska •
<br />APPROXIMATE INTERVAL
<br />mast toc
<br />1 Hour.;
<br />Onset to death
<br />> 10 Years
<br />onsettOdt:it
<br />19. WAS MEDICAL EXAMINE*
<br />OR CORONERCONTACTED?.
<br />❑ YES j ®.NO
<br />21c. WAS AN AUTOPSY FERMI*)
<br />❑ YES al NO
<br />21d. WERE AUTOPSY FINDINGS AVAILAHi:E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 1:1 4/0.:'
<br />rm, Street, factory, office building, construction ata, e! . (3p
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME QF DEATH
<br />24d. T)ME PRONOUNCEiD 0
<br />24e. Dn the bisis of examination and/or investigation, ht my Opkewi deatltaacurrldii
<br />'abs time, date and piece and due to the cause(s) stated. (Si9n*tureaqd ffele)
<br />26a. HAS ORGAN OR TISSUE DONATION
<br />0 YES NO
<br />BEEN CONSIDERED?
<br />QQNTRIBUTE TO THE DEATH?
<br />❑ NO PROBABLY ® UNKNOWN
<br />NAMP:T14LEANDADDRESSOFCERTIFIER (Type orPrint
<br />Cinoa K.'Ritchie, APRN, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT:Cs
<br />Not Applicable if 28a Is. NO
<br />28b. DATE FILED BY REGISTRAR (Mo:, Day,}Y(,)
<br />December 3, 2018
<br />
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