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< ETA_TEi)F_NEERAEKA_.
<br />dill/A91Ud)A>,• Whhri@dADsce °:gatdd44ty;/'I�.iCdAASoa= :oshhhhMl@AS� v r 6ttddr/lyiiICAAFIa� <crithrrpp„as
<br />I'. iS COPY C, RRIES`THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />A~'TRUE oppYoKIVIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />II►;SERVICES, 1AITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />TE`O.FISSU itCE
<br />8 9/2024'
<br />LIN(,N NEBRASKA
<br />err I
<br />J rArnie
<br />1Y AND STATE OR TERRIT
<br />202501700
<br />SARAH BORNE
<br />ASSISTANT STATE
<br />DEPARTMENT OF HEALT
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Idd le, Last, Suffix)
<br />Y, OR FOREIGN COUNTRY OF BIRTH
<br />give street and number)
<br />ode Zip Code)
<br />9b. COUNTY
<br />Hall
<br />;A AT liME OF DEATH ❑ Married 0 Never Married
<br />dowsd 0 Divorced 0 Unknown
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />94
<br />Sb. UNDER 1 YEAR
<br />$a. PLACE OF DEATH
<br />HOSPITAL ❑ inpatient
<br />❑ ERIOutpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Donipban
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />OTHER 0 Nursingilome1t'
<br />0 Decedent's_ Horn
<br />® Other
<br />Ed. COUNTY OF DEATH
<br />Be. APT. NO.
<br />9f. ZIP CO
<br />68832
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If Mfg,
<br />Carl R Amick
<br />. FA 15•,NAME (l het, MI IA Last, Suffix) J 12. MOTHER'S -NAME (First, Middle, Maiden So
<br />Charlie"::..:: Xtuctss�n i Victoria Johnson
<br />Give dates of service if Yes.
<br />14a. INFORMANT -NAME
<br />John Amick
<br />16a. EMBALMER -SIGNATURE
<br />Jacob Nutz
<br />fed. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Minden Cemetery
<br />ONES iM E AND MAIUNG ADDRESS (Street, City or Town, State)
<br />3utlerRvollandFuneral Home, 1225 N. Elm, Hastings, Nebraska
<br />�quantialfy itet'cofdldaf
<br />ae+ dNsaw, injuriss, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />nation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines 9 necessary.
<br />IMMEDIATE CAUSE:
<br />A) Kidney Failure
<br />16b. LICENSE NO.
<br />1543
<br />CITY I TOWN
<br />Minden
<br />CAUSE OF DEATH (See instructions and examples)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Chronic obstructive pulmonary disease
<br />• OR AS A CONSEQUENCE OF:
<br />si i14ptiu NtO:CAUSE C)£ iastolic heart failure Disease
<br />w or')i�i)iy that titilCreted
<br />ants �g in {iem) ,DUE TO, OR AS A CONSEQUENCE OF:
<br />d tobacco use
<br />rAFYI',il:Ram CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I
<br />r of death
<br />ear before death
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending tnvaetigation
<br />0 Suicide ❑ Could not be determined
<br />Yt) 22b. TIME OF INJURY
<br />2113. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />E HOW INJURY OCCURRED
<br />T & NUMBER, APT.NO. CITY STATE
<br />Day, Yr.)
<br />23c. TIME OF DEATH
<br />07:41 PM
<br />ilfhlN knowledg death occurred at the time, date and place
<br />r;.apY ej lteted. (Signature and mle)
<br />TO THE DEATH?
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24e, On the bails of examination and/or Investigation, In
<br />the lime, date and place and due to the cause(*) eta
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />ABLY 0 UNKNOWN ❑ YES ® NO
<br />CERTIFIER (Type or Print
<br />I W Faidley #400, Box 9802, Grand Island, Nebraska, 88803
<br />26b. W
<br />Not Apat
<br />26b. DATE F(
<br />Augus
<br />2.
<br />Mo
<br />
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