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ADAMS COUNTY NE
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-- -• STATE OFxNEBFRASKA ~. 161 O O
~. 0.'56 9
WHENTH/S COPY CARR/ES.THE RAISED SEAL,OF. THE NEBRASKdHEALTH'AND HUMAN'SERVICES
°. `,SYSTEM, IT CERTIFIES;THE'BELOWtTO`BE;AjTRUE COPY OF.THE+ORIG/NAC'RECORD ON;FILE WITH. '
"THE NEBRASKA~HEALTH'AND HUMAN,SERVIEES. SYSTEILi;~ VITAL §TATIST/CS'SECTION, WH/CH7S
THE LEGAL DEPOSITORY.FOR VITAL. RECORDS:: t ;
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)OATE;OFISSUANCE , : •
. ,~~~ ~
TANLEY S. ~
~:MAR`,2 6'''2007.: , '..:. .. ;: cooPeR.
- `ASSISTANT STATE REG/SiRAR
• dLINCOLN, NEBRASKA- ~ - ~ ~'' E '
_ .,..... ,. .,.. , ' ' ~ - HEALTH AND'HUMAN.SERV/C S
,...
' _. -~,~ STATE OF NEBRASKA'-bEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP~r7n~Tyqq~~ ,
. ~ `-~. TCQTICI(`ASF'fl F~f1FATH• ':.. _.. ~ ...11~" / ~~..-1.. `~
1: DECEDENT'S"NAME(Firs 1, -Mldtlle, ..., ~'~. .`."Last„'... :SUIIi%) ~
'
2. SEX ~ -__
~3. DATE OF DEATH (MO., Day;Yr.)
.. : .
.Donnie Ray Arnoldy . _ '.. :.:.. ,. .. , ;
~
Male-
March 15, 2007
' A. CITYAND57ATE OR.TERRITORY,OR FOREIGNCOUNTRY OF.BIRTH'~
.
.., 5a~AGE~Lae4Blrlhdey~ 'Sb:UNDER (YEAR 6c.UNDERI DAY ~6. DATEOF BIRTH (Mo„Day,Yr.t
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~ ~ MOS.
"DAYS.
.HOURS
~ MINS.
~. 1 :Beloit Kansas' ~ ' ":'; ~'. 54' •- AprIl~13, 1952
-._
]SOCIAL SECURITY NUMBER j ~ - ~ ', ~-
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ea PLACE OF DEATH .. ~ ~,
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509160 6654 ~ t HOSPITAL ~ ~ Inpellenl .-~~,. ~ Q]HER - • ^ Nulsing Home/LTC ^Hueplca Fedllty
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Btl.60UNTY OF DEATH' ,'. t "' `~ "
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.w ` ' .-Hastings:'68901' ~ :. .Adams ~ "°
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~ ..Adams : Hastin s
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Bd. STREETANDNUMBER Ae. APT: NO. 81. ZIP CODE., Ag:INSIDE CITY LIMITS -
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1014 West 11th
68901.
m YES ^ NO
.,~, "105. MARITAL STATUS AT TIME OF DEATH~~ tY1,Marrled U Naver Marred ~ 101i:.NAME OF SPOUSE„(Flrsl, Middle, Leel, SulllX) II wile, glue maiden name. '
a' U Married, but ¢eparaleo ^ Widowed ^ Divorced ^ Unknawn': . • '
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• Judith Gadbu '
~ Surname)
Malde
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Mlddle, ~ -Lael Sullixp: .,.
. 11. FATHER'S~NAME (FUaI, n
e,
S~NAME~ (flrs6 Mid
12 MOTHER
F Ra mo~d'Arnold : •' - - i. - . Elizabeth Baden
13, EVEFl IN U.S.ARMED FORCES]Give dales of service llyes: 14a INFORMANTNAME, ~ ~~ ~ ~ 14D. RELATIONSHIP TO DECEDENT
(Yea, no, orunk.l No' .. ~'' .. ',.... ','.. ~'.iUdy <Afn0ldy ~ ~ " .~ - Wlfe'
' 15. METhIOD OF DISPOSITION 16a.E LMER SIGNATURE ~' ~"~ ~- I6b; UCENSENO:~~~~ .16c. DATE (MO., Day, Yr. ),
~ Bmlal ~ U Donagori • iv ' „J,. J '• March 19, 2007" '
U Crematlon• ^Entombmenl ~ t, tl. CEM YCREMAT OR OTHER LOCATION : ~ '.... _ CITY'(TOWN - ~ ~ STATE
URemaval' ^Olher (Speedy)
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St Bonlface Cemetery ~ .':. - - Tipton
--• ~17e-FUNERALHOME NAME•AND~MAILING ADDRESS_(Slreal Clty arTown, Sle15) . ~. ~ ..
176. Zlp Code
68901
'
Funeral Home 505NBeI!evue •Hastlrigs; Nebraska - -
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Brand Wllso
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EINTE
enla•dieeeees inJlidea orwmpllcellone Thal dlreclly cawed the tleeih WNOT Sriler lerminel evenle such ea cardiac errae4 APPRO%IMAT _ RVAL
Ie, PARTI. Enter the shah of 5v~
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jesplralory eiresh or venlrlcular IlUdllallon wllhbut"showing the dtlblogy DO NOT ABBREVIATE tEnlar only are c5uce on a IInS, Add ~addlAOnal Anes II necaaeery.
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• - ~ JMMEDIATE CADS . . ~ -'~ • ~ / q
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' IMMEDIATE CAUSE(Fh51 • ' (a) ~~"/ "~ ~ ~ • ~~
tlkeece pcandltbnfecuBing „ DU~ O, OR ASA CONSEDUE NCE OF: ~ ~ ~ ~ I Dotal l0 death
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Sequ¢nllelly Ilslcondlllone, ll : ~. IDI ~ ' ~ ~ , ~~ ~
any, leadlnpto Wec5ui51kled. DUEiO, OR~ASACONSEDUENCE'OF:. I onael l0dealh
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EntN hs UNDERLYING CAUSEI ~
(disease or hlury Ihal In11151ed- (c) ~ ~ : .:... " 1
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I angel lodealh
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Iheevanbrseutlinghdeetlrj ~.; DUE TO, GRAS ACONSEpUENCE OF: '"~. ~",.
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PART II:OTHER SIONIFICAIJT CONDITIONS~COndlllons bonldbulinp lolhe da5lh but not rSeUlllhg In the dndertying cause Arven In PARTI.. ~~ ~
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~~ Ig:WAS'MEDICAL E%AMINER
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. ~OR CORONERCONTACTED7.
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~ 21a MANNER OF DEATH - 21 D.IFTRANSPORTATIONINJURY 21c. WASANAUTOPSY PERFORMED?
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20:IF FEMAL
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l~Nalulal: ~ •^DdverlOperalor'
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^ Nol pregnant wllldnpasl year _
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^ YES ~ NO~
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"^ . ,^Pessengef
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U ^Prepnanl al lime oldealH` :: fr
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Pending
nves
Accldenl
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UTOPSY FlNDINGS AVAILABLE TO
^ Nol pregnant, but pragnant vdlhln42 days of tleatlt `. ^SUldde`^Could not he determined ~ 21d.WEREA
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^ Nol preAmnl, but piegn5n143 days to t.yearbel5re deatll ~ ~ '., ~ COMPLETE CAUSEOF DEAT
'
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VES ^ NO
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'S. U Unknown llpregnanl wllhln the past year, ~ ~ ~ -
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' 22a: DATE OF INJURY (Mo:, Day, Vc)
226. TIME OF INJURY ' ng, conslrucdon slle. etc.(SDedl
22y. PUCE OF INJURY-AI home, term, slraet, laclory, ollice bulltll Y)
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22d.INJURY Af WORk7~ j j22e. DESCRIBE HOWINJURY OCCURRED ..1... ~ .. .
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• ' STREETB NUMBER,APL NO.I ),,^^ ^~~CITV7TOWN~ '_ „', ~ STATE ZIPCODE
22T LOCATIOIJ OFINJURV"
...
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~- DATE OF DEATH1Mo; Day Yr) 1. ,... aW - 2Aa. DATE SIGNED (Mo., Day,YC) 2Ab.TIME OF DEATH m
~23a
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March 15, 2007 Bob r, _
o
~ '$=k 24r PRONOUNCED DEAD (Mo., Da Yc),' '21tl. TIMEPRONOUNCEOOEAD
23c TIME OF DEATH ;', "" , y'
...
23b, DATE SIGNEO (Flc„TJey Yr) ~~
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,, 1 6::45 pm E ~ <~ -
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...p]~rch, 20 2007 (
8 op _
- ~ E,°,jz01 21e. On the bssle of ekerNlietlon analorlnveallgellon, In my,opinlon deelh occurred at
e le ana lace
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23 d. To lheD lei wladga dealho urre
P .,F pm ~ Jhe Ilme, tlele grid place and sue to the cauee(a) slnled: (Slgnalwe end.7111e j ~
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25. DIDTOBACCO USE CONTRIBUTETOTHE DEATH7-~~ ~-~ ~26a.HAS,ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26D. WAS CONSENT GRANTED].
pp ^ YES L*NO ,^ PROBABLY ^ UNKNOWN." ^ YES t '77 NO Nol Applicable 1126a is N0 ^ YES ^ NO
1
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TITLE ANDADDRESS OF CERTIFIER,(PHYSICIAN~CORONERSPHYSICIAN ORCOUNTV ATTORNEY)(rype or Pnnq
NAME
27
,
.
Robert'L. Mastin,.MD, 10 1 West 14th,_.Hastings:;'NE 68901
~
I ' 28b.0ATE FILED BY REGIS TRAR (Mo., Day, YlJ
'
28a, REGISTRAR'S SIGNATURE ,V , , ;_,
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" MAR ~ ~ 2DD7
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