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<br />IIS 3iA' of CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />A TAIJE 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 1S UANCE
<br />7/2 / 4'
<br />LINCOL+N, NEBRASKA
<br />2025 05 51 0 ASS STANT STATE REGIS
<br />DEPARTMENT OF HEAL`
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />4EiDEM ..S.t Velfirst, Mlddie, Last, Suffix)
<br />uiti : o 4.rertts
<br />4 tort'AND$'f'ATiOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />•.Grand Islsnd;';Nebr`aska
<br />1,.1:otEAL!I!i~CU.41 V.•UUMBER
<br />05.07444 078>•••
<br />.'FACUJTY,)AME'(If'riot InetltutIon, give street and number)
<br />Btookeflekd ;Park
<br />• ep ; :OrrY;.;OR TOWN:OF"DEATH'(Include Zip Code)
<br />St fatal:>=88873
<br />1 RESIDENCE -STATE
<br />Nebraska .:::.....
<br />STr EEtA lcs<NUMSEEt
<br />!!:4204.1,4kAirisOrrROad
<br />t0il,`M RITi s; STATUS ATTIRE OF DEATH ® Married 0 Never Married
<br />C .MerrdW, but sepinited 0 Widowed ❑ Divorced ❑ Unknown
<br />9b. COUNTY
<br />Hall
<br />1 F.A";1NERS41AME" (Fltot, Middle, Last, Suffix)
<br />•
<br />La nce'` Ray; :Geddes, ,
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />63
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />811. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />0 ER/Outpatient
<br />❑ OOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ® Nursing
<br />❑ Decedent's Horns
<br />❑ other (EP«dfy)
<br />3: FATS
<br />ed. COUNTY OF DEATH
<br />Howard
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Conrad Joseph Arends
<br />1t MOTHER'S -NAME (First, Middle,
<br />Helen Mav Townsend
<br />1 t:EMEk IN:ttiti. ARMED FORCES? Give dates of service if Yes.
<br />:4YSs, NO, or Unk,) NO,
<br />4EI.,METHOD_OF DISP:0SITION
<br />:000nlatlon
<br />Crsma*IOn nErgeirribmant 1
<br />.moult ` 'Otter (Specify)
<br />14a. INFORMANT -NAME
<br />Conrad Joseph Arends
<br />16a. EMBALMER -SIGNATURE
<br />Drew J. Schaefer
<br />16b. LICENSE NO.
<br />1435
<br />d. CEMETERY, CREMATORY OR OTHER LOCATION' CITY / TOWN
<br />Nebraska Cremation Service Norfolk
<br />.:FIENERALHOME:NAME AROMA LING ADDRESS (Street, City or Town, State)
<br />e ander`rur era(:'1-tome of Elgin, 107 Pine St, Elgin, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />I. Enter #M ahaht of Mal tWs+ diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />.tr ventricular 6brhtation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />*Cardiac arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) respiratory depression
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Severe Alzheimer's dementia
<br />18; ?ART:11. OThERAIGNlFICANT CONDITIONS -Conditions contributing to the d.athN:but not resulting•:
<br />Attupiytottlt rroidj anxiety, chronic kidney disease, Gastroesophageal reflux
<br />P+aFtnitif:i.
<br />Net pre ii
<br />E1 Not pregn
<br />tlMwown;t
<br />DA1rE ¢F
<br />22d:, INJURY A
<br />" C7 Airs;:
<br />M 42 days of Math
<br />eye to 1 year before Math
<br />tMaat year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending titivestigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />NUMBER, APT.NO.
<br />• underlying cause given In PART L
<br />211e. IF TRANSPORTATION INJURY
<br />© DtfverlOperetor
<br />ElPassenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:05 AM
<br />ath occurred at the time, date and place
<br />(Signature and Title)
<br />EGONT(4IBUTE To THE DEATH?
<br />ABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR SSUE DO:
<br />❑ YES e
<br />CERTIFIER (Type or Print
<br />3 Sherman St, St. Paul, Nebraska, 68873
<br />81Cliity:
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24‘ on the, txuls of examination andior Investigation, to
<br />•`the time, date and place and due to the causes) au
<br />MN BEEN CONSIDERED?
<br />26b. WAS COME
<br />Not Applicablp;if
<br />
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