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Rev. 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS 200204528 CERTIFICATE OF DEATH ICI C 0 O U C O O .� U O E QCj c0 X Ico U N Z E W p c LU .ca U .0 w � L LL CL O-0 W m 3 Z LL co M FOR VITAL STATISTICS USE ONLY Place ....................... A ................................ B ................................ C ................................ D............................. E Part II TMV........................... ... . ............................... ...................... NSC........................................................................................................................................................................................... ............................... .........................Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject ............................................................................................................................. ............................... .................... ................................... ............................... & Printed with soy Ink on recycled paper 6 I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITALS ISTICS IN LINCOLN, NEBRASKA. APFEL- BUTLER - GEDDES FUNERAL HOME 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH !Month. Day. Year) Arnold Orlando Kinney Male May 10, 2000 4. CITY AND STATE OF BIRTH pf not iv U.S.A.. name country/ Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monlit. Day. Year) Petersburg, Nebraska (Yrs.) 77 Sb. March 1, 1923 MOS. I DAYS 5c. HOURS MINS. 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 508 -16 -0788 HOSPITAL: ® Inpalient OTHER: ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY -Name (1f not insfilubm give street and numberl St. Francis Medical Center ❑ DOA ❑ Other (Spealyi 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ® Nd ❑ Hall 9a. RESIpENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /including Zip Codel 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 220 West Phoenix Ave. Yes ® No ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican, German, etcl 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE pl.wife. give maiden name) etc.) fSpec white (Specify) American NEVER DIVORCED Alberta Strickland ARRI 14a. USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary o S condary 10.12) College 11.4 or 5-1 1 of workin life, even ifrerired) Ware�ouse Supervisor Kelly Supply Company 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME ' William Charles Ki ney Sophie Anne Thompson • 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes. no. or unk.) (It yes. give war and dates of services) Yes: II 2 -3 -43 12 -5 -45 Alberta Kinney 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 20 West Phoenix Ave., Grand Island, NE. 68801 120. EM ALMER - SIGNATURE 6 LICENSE NO. �2 21 a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY -NAME � 4 © Burial ❑ Removal May 13, 2000 Mount Pleasant Cemetery 22a. FUNERAL NOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes ❑ cremation ❑ Donation Petersburg, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE CAUSE (� (ENT`ER� ONLY ,ONE CAUSE PER LINE FOR 1.). IIb). AND (c)) I Interval between onset and death PART) V `il`r^CW VI \1� 1�l�VIW .]-�v i DUE TO, OR AS A CONSEQUENCE OF! , n I Interval between onset and death (_0 �] (b) I DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death I I (cl I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but t related PART PART %o III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PREGNANCY ��\''" l �1� 1 ` c ` tV IN THE PAST 3 MONTHS? EXAMINER OR CORONER? El (Ages 10 -541 Yes n No Yes No Yes No 26a. 26b. DATE OF INJURY (Ma. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ❑ Accident ❑ Undetermined M ❑ Suicide ❑ Pending 26e. INJURY AT WORK 261. PLACE QF, INJURY - ppt hom , !arm, street. factory o ce bwld ng, etc. /Specifyf 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation ❑❑ Yes No ❑ 27a. DATE OF DEATH (Mo.. Day. Yr.) �p� `W 28a. DATE SIGNED (Mo.. Day. Yrl 28b. TIME OF DEATH M 27b. DATE SIGNED (Mo.. Day. Yr.) 27c. TIME OF DEATH 2Bc. PRONOUNCED DEAD lMO.. Day, Yr) 28d. PRONOUNCED DEAD (Hour! 129, .��0 � t� N� M ° M � 27d. To the best of my knowledge. death occurred 1 time, date and place and due to the causes) stated. rl 2Be. On the basis of examination and,or investigaGOn. in my opinion death occurred al the time, date and place and due to the causes) slated. �Ck�M � U )S nature and Title) ► i�/-� (Si nature and Title) 10 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES ❑ NO ❑ UNKNOWN ❑ YES NO 1:1 YES �fdtT 31. NAME AND ADDRESS OF CERTIFIER IPHYSCCIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Prinr/ (l--h f-'U* IN tai '4�Pt- LC-'N- (\A -' �-v �t�- ty , 32a. REGISTRAR r. 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) FOR VITAL STATISTICS USE ONLY Place ....................... A ................................ B ................................ C ................................ D............................. E Part II TMV........................... ... . ............................... ...................... NSC........................................................................................................................................................................................... ............................... .........................Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject ............................................................................................................................. ............................... .................... ................................... ............................... & Printed with soy Ink on recycled paper 6 I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITALS ISTICS IN LINCOLN, NEBRASKA. APFEL- BUTLER - GEDDES FUNERAL HOME