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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENi" OF HEAL�'A Q I,�UMA�CI "�f�RVICES,IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITN THE NEBRA�KA�I.�E�PARTM�N�, 0�6H� EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FaR V,�AL• �,���D� •., �`;
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<br />DATE OF ISSUANCE �y.��� � � • � �, � �
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<br />; �TA�VEEY �? � O�P�SR ' �s o�'
<br />, 07/25/2011 �s�'�ranr�s�►���� ;° I
<br />' � 4110 5 7 3 5 ���TMENT a� M�,t�-H A�,� �r
<br />LINCOLN, NEBRASKA PM�lI�,�4iV•S�l � �-,� `^ ^�� �
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<br />' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV'I�F�SC,�. �' • . . . .. . �`J .�., +f'�
<br />CERTIFICATE OF DEATH ° �> .; `� • g �,� = , �-�`' o �,M , ` 1� 02454
<br />I DECEDENT&NAME (FI►st, Mlddle, Last, Suff6c) 2. SEX � 3:,pAT (Mo., Day, Yr.)
<br />' Arnold Junior Placke Male July 15; 2011
<br />, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c.�, UNDER 7 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►g•I MOS. DAYS HOURS MINS.
<br />I Hastings, Nebraska 62 September 17, 1948
<br />ISOCIAI, SECURITY NUMBER ea. PLACE OF DEATH
<br />506 HOSPITAL � InpatleM OT E� Nursing HomeILTC � Hoapice Factllty
<br />8q. FACIUTY-NAME (M not Instidrtion, glve street and number) ❑ ERlOutpatlent I ❑ D�edent's Home
<br />�
<br />� Lakeview-A Golden Uving Center ❑ �oa �� ❑ o�ner (spec�ry)
<br />� BC. CITY OR TOWN OF DEATH Qnctude Zip Code) 8d. COUN7'Y OF DEATH
<br />o ......III Grand Island 68801 Hall �
<br />¢ 8a. RESIDENC�STATE 8b. COUNTY 9a CITY OR TOWN ',
<br />w Nebraska Hatl Grand Island
<br />LL 8d. STREET AND NUMBER 8e. APT. N0. 9t. ZIP CODE 8g. INSIDE
<br />�, 1104 Oklahoma St. 68801 � �s
<br />.� 70a. MARITAL STATUS AT TIME OF DEATH � Marrlad ❑ Never Married 10b. NAME OF SPOUSE �First, Middle, Last, SuHbc) B wffe, gNe rtwiden mame
<br />� ❑ n�mad but separated ❑�nnaowea ❑ �Na.�aa ❑ u�,w,owo Dara Jean Hanssen �I
<br />� 11. FATHER'S-NAME (Firet, Mlddte, Last, SuffUc) 72. MOTHER'3-NAME (Flrst, I Middle, Maiden Sumame)
<br />Amold Placke Delores Stamer
<br />No
<br />�' 13. EYER IN U.3. ARMED FORCES? Gfve datea of service H Yes. 14a. INFORMANT-NAME I 14b. RELATIONSHIP TO DECEDENT
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<br />$ �res, No, or unk.) No Dara Placke Wife
<br />� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE Nd. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ suna� ❑ oonauon Not Embalmed �� July 18, 2011
<br />� CremaUon ❑ EntombmeM 16d. CEMETERY, CREMATORY OR OTHER LOCATION CffY / TOWN STATE
<br />Q Removal ❑ ou,er �speo�ty► �ntral Nebraska Cremation Senrices Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cit�r or Town, Sfate) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska I 68801
<br />8. PART I. E�er the ehain M eveMS-�dlseases, lnJurles, or compllcadona•that dlrectty caused the death. DO NOT enter tarminal eveMS euch ae ce?Ulac artes►.
<br />resplratory artest, or veMHCUiar flbdlladon without ahowing tha eUology. DO NOT ABBREVIATE. EMer onty o�re ceuse on a p�re. Atld eddftlon8l Ilnes It �receaeary.
<br />IMMEDIATL' CAUSE: �
<br />IMMEDIATE CAUSE (flnat a) Rapidly Progressive Dementla I
<br />dtsease or condidon resulUng ,
<br />In death) DUE T0, OR AS A CONSEQUENCE OF: ,
<br />Seque�rtlaliy Ilet condidone, lt b) �I
<br />any, ieatling to the cauae Ilated ''�
<br />on Ilne a. DUE TO, OR AS A CONSEQUENCE OF: i
<br />EnterUre UNOERLYIN6 CAUSE �) I,
<br />jAisaase orin)urythatinitlated �'
<br />the B°e"te "ss"�U"8 �" death� DUE TO, OR AS A CONSEQUENCE OF:
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<br />to the death but not reautUng In the underlying
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<br />� Not pregnaM withln pastyear � Natural � Homicltle � DrlvedOpe�ator
<br />[] aree�M � n� or a�en p n�aaa�s � Pendin8lmestl9�on ❑�^ee� �
<br />�❑ Not pregnarrt, but pregnant wtthin 42 days ot tleath � Pedestrlan
<br />� NM PreBnai!R. bu�iregna�K49 days M.1.yearhelace tleath .._ ❑ Sulclde � Could nM be tleterm��red . � (
<br />� Unknown If pregnairt wlthin tha pasS year
<br />APPROXIMATEINTERYAL
<br />orreat to death
<br />4 Weeks
<br />onset to death
<br />onsetto death
<br />onsetto death
<br />gfven In PART 1. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEDT
<br />❑ YES � NO
<br />N INJUR 27c. WAS AN AUTOPSY PERFORMED?
<br />❑ ves � No
<br />21d. WERE AUTOPSY FlNDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH9
<br />- -- _
<br />❑ YES ❑ NO
<br />ta. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, oftice buitding, constructlon stte, eta (SpecHy)
<br />2d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO I
<br />2f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlI'OWN i TATE ZIP CODE
<br />�
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />July 15, 2011 .� � �
<br />�} 23b. DATE SIGNED (Mo., Dey, Yr.) 23c. TIME OF DEATH �� k r 24c. PRONOUNCED DEAq (MO., Day, Yr.j 24d. TIME PRONOUNCED DEAD
<br />� Jul 15, 2011 02:43 AM �' a o
<br />�' � Sd. To the beat oi my knowiedge, deatf� occurted at the dme, date and piaae $� 24e. On the baels of examinafl n end/or inveatigadon, In my opinion tleath oxurred et
<br />� end due to the causa(s) smted. (SlgnaWra antl Titlel �&� the dme. date and P�S� nd due to the musa(s) statad. (Signature and Ttde)
<br />David R. Colan, MD '' $ � �
<br />i. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN
<br />❑ YES � NO ❑ PROBABLY ❑ UNFWOWN ❑ YES � NO
<br />�. N E, 7 LE D D F ER ER P , I ST R E C
<br />' David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />!a. REGISTRAR'S SIGNATURE
<br />1'�r,.�.�.I��._ �3_
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<br />Not Appltcable H 28a Is NO ❑ YES ❑ NO
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 22, 2011
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