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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAfASTIGS'6E677A j_ WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ "TANLEYSC DATE OF ISSUANCE 2 0 0 5 0 4 5 7 5 CDCiPER
<br />MAR 17 2005 = ASSISTANT sweREGISMAR
<br />LINCOLN, NEBRASKA FWEALT-H AND HUMAN - SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FITUANC-LAND SUPPORT
<br />CERTIFICATE OF DEATH Q� 02950
<br />1. DECEDENT'5•NAME (First, Middle, Last, Suffix) 2. SEX -- J. DATE OF DEATH (Mo., Day, Yr.)
<br />Arden Dean Richardson Male March 11, 2005
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE -Lest Birthday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />Riverton, Nebraska. (Yrs.) 70 1O DAYS HOURS MIN5. May 7, 1934
<br />7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br />507 -34 -5834 HOSPITAL:
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Pier Park 500 South Oak
<br />Sc, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />U Inpatient OTHER: U Nursing Home /LTC ❑ Hospice Facility
<br />U ER /Outpatient U Decedent's Home .
<br />U DCA X1 Other „Pier_ Park
<br />8d. COUNTY OF DEATH
<br />- Hall
<br />9a. RESIDENCE-STATE 9b, COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER 9e. APT .NO 9f. ZIP CODE
<br />1113 S. Greenwich 1 1 68801
<br />1 Oa. MARITAL STATUS AT TIME OF DEATH L.Marded U Never Married I lob. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name
<br />❑ Married, but separated El Widowed El Divorced ❑Unknown Mary Ann M. Rogers
<br />11. FATHER'S-NAME
<br />- (First, Middle, Last. Ix
<br />MOTHER'S -NAME (First,
<br />Harvey Richardson Grace
<br />Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME
<br />(Yes,no,orunk.)Yes: 6/14/1956 6/13/ 958 Mary Ann M. Richardson
<br />15. METHOD OF DISPOSITION 169. EMBALMER• TURE 16b. LICENSE N0. y
<br />❑ Burial ❑ Donation �v
<br />WC%ramatlon E) Entombment 16d.CEMET RY,CREMATORYO 0 HERLOCATION CITY /TOWN
<br />❑Removal ❑ other (Specify) Central Nebraska Cremation Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NF.
<br />99. INSIDE CITY LIMITS
<br />M YES ❑ NO
<br />Middle, Malden Surname)
<br />Hamilton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo.. Day, Yr, )
<br />March 14, 2005
<br />STATE
<br />Gibbon, Nebraska
<br />16. PART I. Enter the chain of eveatg- -diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a .ine. Add additional lines II necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUSE(Final
<br />_._'a', Car u_la.c....._eyent
<br />disease or condition resulting
<br />DUE TO, OR ASA CONSEQUENCE or:
<br />in death)
<br />_ l.Q.:00 &1.2_:_31L...p m.... _ ....
<br />Sequentially list conditions, if
<br />(b)
<br />any, leading lathe cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />12:54 m
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />(o)
<br />the events resulting In eat
<br />_._.. ..... .. �..._._....- --
<br />DUE T0, OR AS A CONSEQUENCE DF: .,...
<br />LAST
<br />cause(s) stated. (Signature and
<br />(d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I
<br />26. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />LJ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />21a. MANNER 05 DEATH 21b. IF TRANSPORTATION
<br />fall Natural U Homicide ❑ Driver /Operator
<br />U Accident❑ Pending Investigation ❑ Passenger
<br />❑ Pedestrian
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />I
<br />I
<br />onset to death
<br />1
<br />I _ _
<br />I onset to death
<br />I
<br />I onset to death
<br />I
<br />1 onsettodeath
<br />I
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />7t' YES U NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />U YES �J NO
<br />❑Sulclde ❑ Could not bedetermined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />m
<br />22d.INJURYATWORK? 220. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />❑ YES a NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />23a, DATE OF DEATH Mo,. Day, Yr,)
<br />231b. DATE SIGNED (Mo., Day, Yr.) 23c..TIME OF DEATH
<br />Ear m
<br />20 23d.To the best of my knowledge, death occurred at the time, date and place
<br />-8 o and due to the cause(s) stated. (Signature and Title) ►
<br />h G
<br />STATE ZIP CODE
<br />=
<br />24a. DATE SIGNED (Mo,, Day. Yr.)
<br />24b. TIME OFDEATHbe'tween
<br />a
<br />3 14/05.
<br />_ l.Q.:00 &1.2_:_31L...p m.... _ ....
<br />y0
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />�`a z
<br />3/11/05
<br />12:54 m
<br />w
<br />O p
<br />24e. the ba3is ofxKai n and /or Investigation, in my opinion death occurred at
<br />h� Ime,. d"�I d7f to the Title) 'I
<br />+�
<br />e a ce a
<br />cause(s) stated. (Signature and
<br />25. DIDTQBAQCQUSE E DEATH OR TISSUE DONATION BEEN CONSIDERED? \ 26b. WAS CONSENT GRANTED?
<br />G YES ❑ NO U PROBABLY CX UNKNOWN U YES NO Not Applicable It 26a Is NO U YES U NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN
<br />- - - - - -- _ - - - -- 231 S. LDCUSt St.
<br />OR COUNTY ATTORNEY) (Type orPrint)
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY MA RAB It ,, D�yA
<br />
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