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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SE�4L OF THE NEBRASKA DEPARTMENT Of
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE
<br />HUMAN SERVICES, VITA! RECORDS OFFICE, WHICH IS THE LEGAL DEPOS,ITOR�* ,F,�
<br />DATE OF ISSUANCE
<br />01/31/2011 2011�9�1 ` ��!
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S
<br />l�lTt.i.�1Nfl f°I!lM;Ql1l SE�VICES,IT CERTIFIES
<br />�j�lG4 ,l��P'�AR�p7Elil� D� ME;4LTH AND
<br />YI�iA�eIZ�C{IRD,,�' y ,. ,� ;.
<br />��� �o,�f �� ,
<br />�C�� � ��"�!�','' '
<br />V'L�Y'�,�� �(�1aRER '�', . , , ,
<br />�I��N�`�?�'':1-tEi4tTH AND ;
<br />� 5�lZVTCES
<br />♦., ��r � t �;'� r �. � 71 00242
<br />CERTIFICATE OF DEATN � `'u „ '',��~ ' • -
<br />1. DECEDENTS-NAME (Firat, Mlddie, LasL SuHlx) 2 SEX °. �, `�" `_� 3r D TE OF �EATH (Mo., Day, Yr.)
<br />Rodney LeRay Resh - Ma�e � January 24, 2011
<br />4. CITYAND BTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. A08 • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Has�ngs, Nebraska 69 August 2, 1941
<br />7. SOCIAL SECURITY NUdIBER 8a. PLACE OF DEATH .
<br />507-�44-7063 OH SPRAL � Inpatlent THE ❑ Nursing Hame/LTC � Hosplce Facllily
<br />Sb. FACILITY-NAME (N not I�reGtutlon, ghre street arM m�mber) � ER/Outpatlent ❑ DeeedeM's Home
<br />�
<br />� Saint Francis Medical Center ❑ DOA ❑ Other (Speclfy)
<br />v
<br />� 8c. CITY OR TOVYN OF DEATH (I�lude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Halt
<br />� 8a. RESIDENCE�STATE 8b. COUNTY 9e. CITY OR TOWN
<br />w Nebraska Buffalo Shelton
<br />7 8d. STREET AND NUMBER 8e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMff3
<br />LL 509 A.St P.O. Box 33 '�, 68876 � YES ❑ No
<br />� 10a. NWRITAL STATUS AT TIME OF DEATH � MaRied '❑ Never Martied 10b. NAME OF SPOUSE (First, Middle, Last, Suftlz) If wHe, gNe malden rmme
<br />� ❑ Marrled, but separeted ❑ Widowed ❑ oNorcea ❑ umcrrown Judith Schmidt
<br />� 11. FATHER'S-NAME (Firat, IWddle, Laet, Sutfix) 12. MOTHER'S-NAME (Firat, Middle, Maiden Sumame)
<br />m Thurl Resh Mildred Day
<br />°' 13. EVER IN U.S. ARMED FORCES4 Give datea of sanice UYes. 14a. INFORMANT•NAME 14b. RELqTiONSHIP TO DECEDENT
<br />E
<br />$ �rea, No, or unic.) No Judith Resh Wife
<br />,� 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ sunai ❑ oo�son Not Embalmed January 25, 2011
<br />� Crematlon Q E�ombmerrt 18d. CEMEfERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ ocn�. (spe��y� �ntral Nebraska Cremat�on Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRES9 (Speet, Clly or Town, Stete) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam es
<br />1& PART I. Frrtar Ure chein oi eveMa• �disaasee, InJuNee, or compllaationa-thet dlrectiy caused the death. DO NOT a�rter temUnal eveMe s�+ch ae cardlac errest, ; AppROXIMATE INTERVAL
<br />resptratory erteat, or venMcu�a� Hbr�llaUon wkhout elwwinp the etipiogy. DO NOT ABBREVIATE. EMer only one cauee on a Iine, Adtl adtlfdonsllinee i( necesaery. �
<br />IMMEDIATE CAUSE: ; o�et to death
<br />IMMEDIATE CAUSE (Flnel a) Respiratory Failure ; 5 Minutes
<br />dl9easa or eondiGon resulting
<br />In deafh► DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />aen�e�ua�n n� ��amo�e, x b) Laryngeal Hemorrhage � 24 Hours
<br />em, �eaai�e a �ne cm,se usma
<br />on Il�re a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />��u,� uNn�nNa cause �) �rgess Cancer ; 15 Years
<br />(tltsease or MJury that Initlatetl
<br />the evenm reaulUng �n daath) DUE TO, OR AS A CONBEQUENCE OF: � onset to death
<br />`" d�Tobacco Abuse ' : 30 Years
<br />18. PART II.OTHER SIGNIFICANT CONDffIONB�CondlUone contributing W the death but not resuitlng In the underiying cause given in PART I. 18. WA3 MEDICAL EXAMINER
<br />Chronic Obshuctive Pulmonary Disease OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />� LL 20. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21a WAS AN AUTOPSY PERFORMEDI
<br />� � Not prepnant within past �ear � Natural � Homielde � DrivedOperetor
<br />Preenam at dme of death � Passenper ❑ YES � NO
<br />� V ❑ � Acetderrt � PenAinp Inveatigatlon
<br />� Not pregna�rt, but pregnant wlthin 42 eays at deatM1 � Pedeshian 21d. WERE AUTOPSY FlNDINGS AVAILAB
<br />� swdde coma �roc ae dese��red
<br />❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />�� � Not P�48�a�►. but P�e9nant 43 daye M 1 Y�r betore death � Other (BPecltY)
<br />a � ❑ Unknown fl P�9nant wfthin tire Past Year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mp., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•A! home, farm, street, tactory, offlce building, co�truetlon ake, etc. (Specify)
<br />s
<br />.S 22d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />I�-
<br />❑ YES ❑ NO
<br />22f: LOCATION OF INJURY • STREET 8 NUMBER, APT.N0. CITYITOWN S7ATE ZIP CODE
<br />23a. DATE OF pEATH (Mo., Day, Yr.) ` 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� � January 24, 2011 � � a
<br />�� Y 23b. DATE SIGNED (Mo, Day, Yr.) 23e. TIME OF DEATH �� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Janua 25, 2011 02:33 AM a<�
<br />$� � To the heat oi my knowledge, death oaurted st the Ume, tlate and P�e ��� 24e. On the basie of examinatlon endlor Invesdpatlon. ln my oPlnlon deatM1 oceurted et
<br />�- and due to tha causa(e) statetl. (Sipnature a�M Tltle) � the Gme, date and ptace and due to the eauee(s) atated. ISIB�re end Title)
<br />o $
<br />~� Larry L. Hansen, MD '" s
<br />25. pID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED7
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable fl 28a la NO ❑ YES ❑ NO
<br />27. IT D O TIFIER (P I RO E P C R RN (Type or PriM)
<br />Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIQNATURE �+ . ' 28b. DATE FlLED BY REGI3TRAR {Mo., Day, Yr.)
<br />January 26, 2011
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