|
)�Q J 6ANddASst h� {"5234619,p�tt�tlPdd3D.+
<br />STATE OF NEBRASKA
<br />239f.I7.i1t1.11dist,,,:: `=vrteavat•
<br />WHEN';T"Hi$'i COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, Jr: CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY oF;THE ORIGINAL RECORD ON FILE WITH: THE NEBRASKA ,DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, •tam. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Dtf7E PISSUANCE
<br />1 /24r2024
<br />LINCOLN, NEBRASKA
<br />�.. 3���+..yri.Jr�
<br />2 0 2 5 0 6 2 3 SARAH BOHNENKA
<br />7 MP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />C#E#QEN:1." NAME: (First, Middle, Last, Suffix)
<br />arrt '>>Rus'sell.. 'Batie Jr
<br />4.01
<br />CERTIFICATE OF DEATH
<br />ATE:OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />C.h.ad roll.,. Nebraska
<br />'7.;8OCtillLEEirUR('f NUMBER
<br />fib:<FACIi1TY #1A ME (Irnot Institution, give street'and number)
<br />415 Campbell Avenue
<br />8c.:.CI f.QR_T for.DEATH (Include Zip Code)
<br />' 00t11pha'fl >'6883. t2..;:'
<br />9a. RESIDENCE:
<br />Nebraska
<br />110„A OgT AND NUMBER
<br />'#S;Carnpbeil Ave ue
<br />9b.000NTY
<br />Hall
<br />tits MA Rfl :I A"f:'UQ:AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11.;FA HER'SyNAME;;CFlfet, Middle, Last, Suffix)
<br />fames. ;:Russell ;'Batie
<br />13,:EVER IN U' u: ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) Yes 07/27/1956-07/26/1958
<br />16. METHOD OF DISPOSITION
<br />❑:' Btrr 81 >'E t 1 Donation .
<br />Cremittlan: C] Entontbmsnt
<br />flamovat":"' ] other (Specify)
<br />50,..AGE • Lelaeirthdtty:
<br />(Yrs.)
<br />88
<br />5b: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />IfIL PLACE OF DEATH <.
<br />HOSPiTAl .:© inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />24 00 2
<br />3. DATE OF 0.047T::(Nt+D, C. Y[; s'(:)
<br />January '1. 24
<br />OF R'#I: Mo. blab: Yr )
<br />6. DATE
<br />May 9, 1935
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />10b. NAME OF SPOUSE {First, Middle, Last, Suffix) M wife, gtrimaiden naffs:
<br />Ruth Ann Howard
<br />12;MOTHER'S.-NAME (First, Middle, Maiden
<br />"' ;arrbl' C Stroud
<br />14a. INFORMANT.NAME
<br />Ruth Ann Batie
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR QTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a.,F9NERAL,HO04E,E AND MAILING ADDRESS (Street; City or Town, State).;Ail Fithur(NAMal;ome, 2929 S. Locust Street, Grand Isle;nd„ .Nebraska:
<br />CAUSE OF DEATH (S
<br />Instructions and examples)
<br />12. PART I. Enter Oa chain s-dtgaaas, injures, or complications -that directly caused the death. DO NOT tinter terminal events such as cardiac arrest,
<br />nsptatary arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary,
<br />IMMEDIATE CAUSE: .
<br />It1efft* ECAUSRIihwi "°; a) Unknown Natural Causes
<br />d(µsea+ o0rtl0000 nisui000
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditbM, it b)
<br />any, Medina** the cattail listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eitt 1ItaLiNDERk:Y1NGCAU$E c)
<br />(dis+a of nnitiUty:that' lotU iiad
<br />the events resulting in See" DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />1>p;"PART'11. OTHER:SIGtUFICANTCONDITIONS-Conditions contributing to the death Out not tea:ttitingin tht Underlying cause given In PART I.
<br />t igt16fieiesta(ol;<.epllepsy, diabetes, enlarged prostate, hypertension;high blood pressure
<br />20 IF,F,EMALE:,
<br />0-ry Noteoten r4ftt(1n'pistyear
<br />Cr preens:et gs trite r:9esth^::
<br />rI NQt PtstinO!ft btotposfIiNM wft idn 42 demi of death
<br />© Not pregnant, but pragnant43 days to 1 year before death
<br />0 Unknown ir,pragnant,wlthin the peat year
<br />' ti >DATE i2tt::IaJU(2Y:(MU; Day; Yr.)
<br />NJURY AT WORK 1
<br />❑ YES ONO
<br />21a. MANNER OF DEATH
<br />® Natural EINonmic de .>.
<br />❑ Accident ❑: peening Irivestigatl'ori
<br />❑ Suicide a could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAEOF1NJURY.At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />0014110N S 1r.#.( JI1R`R; STREET & NUMBER, APT.NO.
<br />2
<br />ATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />Te the tNw : :knowledge, death occurred at the time, date and place
<br />:MISMi t ltle:46tnie(s) stated. (signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />(3 YES >❑ Nt7:: " ❑ PROBABLY ® UNKNOWN
<br />•
<br />21b..IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Fafsenger
<br />❑Pedestrian
<br />0 Other (Specify)
<br />cif)* tacljHy.;:::::
<br />ls;NO'::
<br />.1+tb, RELATIONSHIP +0.13 CEDENT '
<br />Spouse
<br />1Qc DAiEtMGa�YYr.):i::<::
<br />Ja n usirv>
<br />Nebraska
<br />APPROXIMATE INTERIAL
<br />onsst'to chilli
<br />Unknown
<br />19, WAS MEE I.1GA. EJt1.611f4Et>;:.
<br />OR 00RONERicONTAC'TED?
<br />YES • Q NO
<br />21c. WAS AN
<br />❑ YES
<br />21d. WERE AUTOPSY<FINDINGSAbAfLAB4E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YEs
<br />Koine, farm, street, factory, office building, construction sl
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Ye.)
<br />January 10, 2024
<br />24b. TIME OF DEATH
<br />Unknown
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />January7. 2024 12:69
<br />2de. Ortthe' basis of examination andlor investigation, in my opinion df.Nteeetirrsfl>aI
<br />Me time, date and place and due to the cause(*) stated. (signature ilMtlitiM
<br />Martin Klein, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES i7 NO
<br />27_ NtME1ITLE:;rAND ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, 'Flail 'County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE %/1-4aA ,G7/�
<br />�i a L.e/?,s-rev--::
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If Vials NO 0 NI
<br />28b. DATE FILED BY REGISTRAR
<br />January 18, 2024
<br />0., Day, Yr.)
<br />00
<br />
|