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EH 2 O WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE OCT 2 3 2000 200315361 ASSISTANTS ATE REGISTRAR LINCOLN, NEBRASKA OF NEBRASKA- DEPARTMFEN'T OF HEALTH HAUMDANiSE/R��E SERVICES SYSTEM SPPORT VITAL STATISTICS CRRTTFTCATF. nF DRATH I. DECEDENT -NAME FIRST MIDDLE LAST 2 SEX -- 3. DATE OF DEATH ;htuntn Dav fear) Arnold Wilhelm Obst male Octnhpr 7, 2000 4. CITY AND STATE OF BIRTH rltnolm USA. name country/ Sa AGE Last Binhday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRTH tMonth. Dav Year) October 12, 001 Westlawn Memorial Park 21d CEMETERY OR CREMATORY LOCATON CITY OR TOWN STATE IYrs I 5b MOS i DAYS Sp. HOURS MINS El Cremation Donal'o, Wayne County, 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) _ I Grand Island, Nebraska Nebraska 23 IMMEDIATE CAUSE _ (ENTER ONLY ONE CAUSE PER LINE FOR rat. to). AND Icll Interval between onset ann neam I PART I Meatastatic small cell carcinoma of the L 1320 7. SOCIAL SECURTIY NUMBER ptembe , 8a PLACE OF DEATH - -- 507 -22 -4492 HOSPITAL ❑ In I.- OTHER 0 Nursing Home — _.. ❑ ER Outpatient ❑ Res -deuce 8b FACILITY - Name (if not rnsbtunon. give street and number St. Francis Skill ❑ DOA ❑ Omer ISPrmly — 8c. CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS I Be COUNTY OF DEATH Grand Island Yes ® No 9a. RESIDENCE - STATE 9 COUNTY 9c CITY. TOWN OR LOCATION AND NUMBER lnc!udrng Zip Code) 9e INSIDE CITY LIMITS Nebraska - '- El :STREET I I�V I Yes rX] No ❑ 10. RACE - le. g.. While. Black. American Indian, 11. ANCESTRY le.g.. Italian. Mexican. German, elcl 12. n MARRIED ❑ WIDOWED ! 3 NAME OF SPOUSE ul wAe give maalen names etc./ ISoecilyl White ISpecllyl American L� NEVER DIVORCED 28c PRONOUNCED DEAD 'Mo Day Yr 28d. PRONOUNCED DEAD tHpu•' MARRI x_ 1.4a USUAL OCCUPATION /Give kind of work done during most lab KIND OF BUSINESS INDUSTRY 15. EDUCATIONc • only nrghest g�tle�� leetedl of working tile. even it reared/ �¢� Elementary or�'S�eco�an{aan• 10.121 College I ., . g� — g = A 1 27d To the best of my knowletlge' 0 1 curreq th time. date and of a and due to the cause,sl staled. �� r. 16. FATHER -NAME FIRST MIDDLE LA 17 MOTHER FIRST MILL DBE MAIDEN SURNAME Frank Oh--,t- marip riz n V `V (Yes no or unk.l III yes give war and dales oI sennces) NO Gl ar�vc nba� ___ -- 19D INFORMANT MAILING ADDRESS (STREET OR R.F D NO. CITY OR TOWN. S TE. ZIPI --A?'\n r.l 0.1— —n _ 20 EMB LMER - SIGNATURE 8 LICENSE NO 21a METHODOF DISPOSITION 2_1 `p DATE 21c T:FMETERY OR CREMATORY NAME PREGNANCY "Chronic obstructive pulmonary disease IN THE PAST 3 MONTHS' I EXAMINER OR CORONER T' = , , =' aaral ❑ Remo.al October 12, 001 Westlawn Memorial Park 21d CEMETERY OR CREMATORY LOCATON CITY OR TOWN STATE . FUNERAL E -NAME - �Zga p fel- Butler - Geddes 26c HOUR OF INJURY El Cremation Donal'o, Island Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) _ 1123 West Second Grand Island, Nebraska 68801 23 IMMEDIATE CAUSE _ (ENTER ONLY ONE CAUSE PER LINE FOR rat. to). AND Icll Interval between onset ann neam I PART I Meatastatic small cell carcinoma of the lung. fat 269. LOCATION STREET 7R R F D NO CITY OR TOWry ST =: Homicide InveStigdliOn DUE TO. OR AS A CONSEOUENCE OF office building, etc rSpecty) - Interval between onset in, �?an Ibl DUE TO. OR AS A CONSEOUENCE OF Interval between onset aria dean• OTHER SIGNIFICANT CONDITIONS - Conditions contributing 10 the death but not related PART PART III IF FEMALE. WAS THERE A 4 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PREGNANCY "Chronic obstructive pulmonary disease IN THE PAST 3 MONTHS' I EXAMINER OR CORONER Ages 10 541 Yes No Yes D No Yes No 26a 26b DATE OF INJURY (Mo.. Day. Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined M Suicide f Pending 26e. INJURY AT WORK 261. PLACE OF INJURY At home. [arm, street, lactory 269. LOCATION STREET 7R R F D NO CITY OR TOWry ST =: Homicide InveStigdliOn Yes No ❑ ❑ office building, etc rSpecty) 27a DATE OF DEATH /MO Day. Yr./ 28a DATE SIGNED /M0 0,1, _r 2Bb TIME OF DEATH 10 -07 -2000 '- 3 a $ U z M_ u' 27b DATE SIGNED (Mo. Day. Yr.) 27c. TIME OF DEATH 28c PRONOUNCED DEAD 'Mo Day Yr 28d. PRONOUNCED DEAD tHpu•' x_ 10 -10 -2000 16:53 M �¢� M g� — g = A 1 27d To the best of my knowletlge' 0 1 curreq th time. date and of a and due to the cause,sl staled. �� r. - - -- 26e. On [Me basis 01 exantlnahpn and or investigation. in my opinion death uccurred al the time date and place anr- ;tie In Ine causelsi stated a ° ¢ uu R = L� / .S. nature and Title) ► v ,Sr nature and Title) ► 29 DID TOGA O USE CONTRIBUTE TO E D TH7 00 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 10 b WAS CONSENT GRANTED' vES ❑ NO ❑ UNKNOWN ❑ YES YNO 1 ❑ YES E?117 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type or PnMI William J Lawton MD 2444 1. Faidl y Grand Island, NE 68803 32a. REGISTRAR 321) DATE FILED BY REGISTRAR (Mo.. Day. Yr.1 OCT 2 0 2000 I. I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO —COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITAL STICS IN LINCOLN, NEBRASKA. APFEL— BUTLER — GEDDES FUNERAL HOME GENERAL NOTARY -State of Nebraska 4116 RAYMOND A. OSEKA My Comm. Exp. Nov. 27, 2004