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<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAlit:SEBVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL FlgibiID(RiiiJi.'iW/TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCSsECT/q/i1iiliilGH'is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ ~__~oo~ _ ~~j u, ,c-" c"" ~~. _~ =-.._ --.-.
<br />
<br />DATE OF ISSUANCE k~i;,(-tB1 ~iv- .------
<br />MAY I 3 2006 JJ~~~:]JTANii:~i;:=ioo~~~'~
<br />ASSI$tANt-sTAr~ ~riJln:RiR;-=
<br />HEALTHi~~~~itEWICE.t-
<br />
<br />\,-':;:;,~.:.-
<br />
<br />200609945
<br />
<br />\
<br />
<br />. . ~~ . - , --
<br />--.
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORjh, 6 2 n:: n: c 7
<br />CERTIFICATE OF DEATH U ..' J,-H'} ;'
<br />
<br />1. ~:~~~:::AME: (Firsl'~lorenc:lddle, Ba~~Si:.' .......... Su1fI.) 2F:.ale ~ ::,~~oH~~-2(OOdEr Yr)
<br />
<br />4, CITY AND STAH OR TE:RRITORY. OR FORE:IGN COUNTRY OF BIRTH 5.. AGE:.Lasl Birthday 5b. UNDER 1 YE:AR 5c UNDER 1 DAY 6 DATE: OF BIRTH (Mo, Day, Yr)
<br />
<br />Grand Island, Nebraska (Yrs.) 81 MOS. DAYS HOURS MINS September 8, 1924
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-22-6961
<br />
<br />8a. PLACE OF DEATH
<br />l:lOSP.IIl\L
<br />
<br />o Inpatient
<br />
<br />OTHES; U Nursing Homo/LTC 0 Hospice Faclllly
<br />
<br />8b, FACILITY-NAME (If not in311lullon, give slreet and numbor)
<br />
<br />Xl ERIOutpatienl
<br />
<br />U Doc.d.nl', Homa
<br />
<br />st. Francis Medical Center
<br />
<br />
<br />OM
<br />
<br />o Olher (Speclfy).__. _._
<br />
<br />9a. RESIDENCE-STATE:
<br />
<br />Nebraska
<br />
<br />19bCOUN:all
<br />
<br />Bd. COUNTY OF DE:ATH
<br />Hall
<br />
<br />I:TYORTOWN--~rand Island
<br />
<br />~O 9~~~~~E
<br />
<br />lOb. NAME OF SPOUSE: (Firsl, Middlo, Lasl, Suffix) If wife, give maiden namo.
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />lllI YES 0 NO
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Grand Island 68803
<br />
<br />\"
<br />
<br />",
<br />.,".......
<br />
<br />9d. STREET AND NUMBER
<br />235 S. Sycamore St.
<br />lOa MARITAL STATUS AT TIME OF DEATH ).C1 Mar;;;;;; 0 N.v.r Married
<br />
<br />o Married, but separated 0 Widowod 0 Divorced 0 Unknown
<br />
<br />Arnold R. Baldwin
<br />
<br />II. FATHER'S-NAME (Flrsl, Middlo,
<br />William Edmund Workman
<br />
<br />LaSI.
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First, Middl.,
<br />Alma (NMI) Kleinkauf
<br />
<br />Malden Surnamo)
<br />
<br />
<br />13. EVER-iNU:S-:ARMED FORC~S? Give dalos olservice If yea 1140-iNFORMANT-NAM~
<br />No Arnold R. Baldwin
<br />-- --
<br />i. E BALMER-SI ATURE
<br />, ('
<br />\". '..............
<br />
<br />16 . E:METE:RY, CREMATOR
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />o Enlombmenl
<br />
<br />
<br />
<br />o Cremalion
<br />
<br />CITY /TOWN
<br />
<br />160. DATI: (Mo., Day, Yr.)
<br />May 18, 2006
<br />
<br />STATE
<br />
<br />15. METHOD OF DISPOSITION
<br />\l'l Burial [j Don.lion
<br />
<br />U Removal 0 Olher (Specify)
<br />
<br />Grand Island City Cemetery, Grand Island, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDR~SS (Slreol. City or Town, Slale)
<br />Kleine Funeral Home, 3213 W North Front St.,
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART I. Enter the chain of Avents..diseases, injuriesl or complicatiohS--thal direc!ly caused the death. DO NOT enler lerminal events such as cardiac arrest,
<br />resplralory arreSl, or ventricular fibrillation wilhout showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines If necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dIsease or condition resulting
<br />In death)
<br />
<br />IMMEDlAT~~CAUSE:. 1
<br />" d
<br />(a) .) ',J_ ,+'l.. .r__'_.,,\
<br />D. UE TO, OR ~S A CONSEQU.. ~CE .0. F: ... _,
<br />
<br />
<br />(b) .p... .. ",. .
<br />. t/ -, '1/:.........::-: . ~::".~.__':t<;;'l.t:)~__
<br />DUE TO, OR AS A CO EOUEN E OF:.
<br />
<br />(L-.<-t.~\c_
<br />
<br />( ) Ii
<br />:J. \1''\,.-'i,~'vD''l''-.'',,__
<br />\. ---
<br />
<br />onset to death
<br />
<br />_' __ 3) '''j v.""",., '.. t
<br />
<br />I onset to death
<br />I
<br />
<br />J\'J _~~_ jJd,,<.~
<br />
<br />I onsello de
<br />I
<br />I
<br />
<br />SequenUolly list conditions, If
<br />ony, leodlng to Ihe cause listed
<br />on IIno a.
<br />Enl.rtho UNDERLYING CAUSE
<br />(dlseo.. or Injury thot Inlll'led
<br />the events reSUlting In death)
<br />lA'rr
<br />
<br />(e)
<br />
<br />Dur; TO, OR AS A CDNSEOUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />U Suicide 0 Could nol be determined
<br />
<br />1<;
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />U Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedeslrlan
<br />
<br />o Olher (Specify)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />[j YES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMW?
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlributing 10 Ihe deal bUI nol resulllng in tho undorlying cauSe given In PART I.
<br />
<br />, ,;: ~
<br />'1ct;"'.
<br />
<br />I
<br />i
<br />)
<br />J
<br />dl
<br />{1.
<br />
<br />\,\l\.~___.
<br />
<br />. t;~,~~-~'c '~NNE~:~F:A;~'-t)"~~q,s.
<br />,Sl-flalural 0 Homlcida
<br />o AccidentD rending Investigation
<br />
<br />o YES
<br />
<br />'niND
<br />/~
<br />
<br />20. IF FEMALE;
<br />
<br />" ,
<br />I".~ot prDgnant within past year
<br />o Pregnant at time 01 death
<br />
<br />o NOI pragnant, bul pregnant wilhin 42 day' of dealh
<br />o Not pregnant, but prognanl43 days 10 1 year before death
<br />o Unknown il pregnonl wllhln Ihe past year
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />220. PLACE OF INJURY.AI hom" farm, 3lreel, tOClory, olfieo building, con,lruction slle, ele. (Spaclfy)
<br />
<br />m
<br />
<br />
<br />-22rjli.uURY';'TWORK? - I 22eDESCRIBE HOW INJURY OCCURRED
<br />[j YES U ND
<br />
<br />221. LOCATION OF INJURY c STREET & NUMBER, APT. NO. CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.0. DATE OF Q.EATH J.I'4iI.rPJlY, Yr.)
<br />May 1J, iUUb
<br />
<br />24a. DATE SIGNW (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />08:44 Am
<br />
<br />z>-
<br />~O~
<br />'D(j)~
<br />~~j:;
<br />'ii.a..<C:J
<br />E~>-Z
<br />8ffi!z:o
<br />1lz=>
<br />~~8
<br />o ~
<br />U 0
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) Nd. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To Ihe best of my knowledge, death occurred at the limB, dale and place
<br />and due to Ihe cause(s) staled. (Signature and Title) T
<br />
<br />{,,,:',. (Zll"" (
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEIliH
<br />
<br />24e. On Ihe basis of examInation and/or Investigation, in my opinion death occurred al
<br />the lime, dOle and plae. and duo 10 Iha cause(') slaled. (Signolure and Tillo)"
<br />
<br />. . O~~~___~ U PROBAnLY 0 U~_KNOW~__._._ .O,YES.___ ]S(:NO __.. NOI Appllcablo if 2Bais_N_~_[J YES [j NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />William J. Landis, M.D., 2444 W Faidley Ave, Grand Island NE 68803
<br />
<br />
<br />26b. WAS CONSENT GRANT~D?
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />MAY 1 8 2006
<br />
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