|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALtN Aifil7 H(LM,�111 �ERI/ICES; IT CERI7FIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WI7H THE NEBRASKA f��'BRI�Tl�ElUZ' f�� tfEALTH ANQ,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �VITAL RE�ORD�
<br />DATE OF ISSUANCE ����' Ja��� � r� �� ��
<br />1
<br />1' 1 /30/2011 sraNcE� �s� COOPER ° °' ' `; t '
<br />2 � 12 0 i 4 6 0 DEP��2TM�1UT0 T f�1�AEfi�I ANI� 9{ , ��
<br />LINCOLN, NEBRASKA HUMAN �LCRVICES . � ,� ,�; � �.�' � � � '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES :; T� A �"7'I 03924
<br />CERTIFICATE OF DEATH � 4 '°�' "�
<br />f) �
<br />DECEDENTS-NAME (Fkst, Middle, Last, Suflirz) 2. SE7C ,�� ' 3:'p/!TE OF DEATH (Mo:, Day, Y�.)
<br />Donald Brent Raplen Male � � November23, 2011
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Bhthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8: DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►$•) MOS. DAYS HOURS MINS.
<br />�
<br />O
<br />V
<br />�
<br />0
<br />�
<br />W
<br />Z
<br />LL
<br />5.
<br />a
<br />�
<br />�
<br />�
<br />r
<br />m
<br />a
<br />E
<br />3
<br />m
<br />a
<br />�
<br />�
<br />W
<br />�
<br />�
<br />W
<br />V
<br />.G
<br />a
<br />�
<br />m
<br />a
<br />E
<br />8
<br />.�
<br />0
<br />�
<br />Grand Island, Nebrask�
<br />. SOCIAL SECURITY NUMBER
<br />1715 Doreen St
<br />CIT'Y OR TOWN OF DEATH pnclude Zip Code)
<br />Grand Island 68803
<br />Nebraska
<br />68 December 16, 1942
<br />8a. PIAC� OF DEATH
<br />H0.SPRAL � I�atleM OTHER ❑ Nureing Home/LTC � Hospice Faellity
<br />I number) � ER/OutpaUerrt Q Decedent's Home
<br />❑ DoA ❑ other (�PetKY
<br />pe
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />COUNTY 8c. CITY OR TOWN
<br />Hall Grand Island
<br />8e. APT. NO. 8f. ZIP CODH 9g. INSIDE CITY LIM11
<br />1715 Doreen St 68803 � r�s ❑ No
<br />a. MARITAL STATUS AT TIME OF DEATH � AAarrlal ❑ Never MarHed 10b. NAME OF SPOUSE (First, Middle, Last, SuRhc) If wife, give maiden �me
<br />p�msa, nue senaraeea p v�naowea ❑ oworcea ❑ u�,tmown Salty Ritchie
<br />. FATHER'S-NAME (Ftrst, dAiddle, Last, 3uFfbc) 72. MOTHER'&NAME (First, Mlddle,
<br />Donald George Rapien Marguerite Pfluckhahn
<br />. EVER IN U.S. ARMED FORCES? Give datea of service H Yea. 14a. INFORMANT-NAME
<br />(Yea, No, or Unk.) NO Sall Rapien
<br />. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO.
<br />❑ eunai ❑ oo��on Not Embalmed
<br />� Crematlan ❑ F.ntombmerrt 78d. CEMETERY, CREMATORY OR OTHER LOCA710N CITY / TOWN
<br />❑ Removal ❑ Other (Spectfy)
<br />Central Nebraska Crematlon Services Gibbon
<br />a. FUNERAL HOME NAME MID MAIUNO ADDRESS (Street, Cily or Town, Stete)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />Malden S�uname)
<br />74b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />November 23, 2011
<br />STATE
<br />Nebraska
<br />77b. Zip Code
<br />68801
<br />& PART I. Eneaztlre cham ot evema--d1�, InJurtes, or camplleadmre-thet diredty cause9 the death. DO NOT e�rter te�mtnel eveMe euch ae cardiac arrest,
<br />mt
<br />respl[aMry arteat, or veMricutar ft6rWadon wkhout showing fhe etlology. DO NOT ABBREIlIATE F�ter onry o�re cauae on a IUre. Add eddidonal Ipres (/ newssary.
<br />IMMEDIATE CAUSE:
<br />�rma�owre cause � a) Failure Of Oral Intake With Dehydration And Electrolyte Imbalance
<br />dlaease w conditlon resulting
<br />��� DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequemia��y net condwona n b)
<br />anY. leadhtg lo the cause Oated
<br />on Wre a DUE TO, OR AS A CONSEQUENCE OF:
<br />EnOer Gre UNDERLYMO CAUSE C )
<br />(tllaeasa or InJury that Initiated
<br />��"� �"� �" �� DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />rnRr u. orH�
<br />� NM PreB� wHhln P� Y�
<br />� Pregnant et Bme of death
<br />❑ Not v�e8�a�rt. but pregnant wWin 42 OaYa of death
<br />� Na P�B��R. but preg�mtrt 49 tlaye l01 year betore 0eath
<br />� Unlmown H preg�mnt Wfhin the pas! year
<br />2a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME
<br />W the death but not reautUng in
<br />:1a.NUWNEROFDEATH 21b.IFTRANSPOF
<br />� Nadual � Homicitle � DriverlOperatof
<br />� AecltlerR � PeMIn9 imeall8�on ❑ Passen9er
<br />� SWcide � Coutd not be determined ❑ PedeaMan
<br />❑ ou,er esae�r)
<br />APPROIOMATE INTERVAL
<br />onsetto death
<br />6 Months
<br />or�et M deaN
<br />or�set to death
<br />cause glven In PART I. 18. WAS MEDICAL EXAANNER
<br />INJURY � 22c. PLACE OF INJURY-At home, farm, atreet factory,
<br />❑ YES ❑ NO I
<br />L �OCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DFATH (Mo, Day, Yr.)
<br />� November 23, 209 9
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Z November 23, 2011 01:58 PM
<br />� � 9d. Ta the beat of mY Imow�ed88. d�th occurted et tire tlme. daCe a�M place
<br />� ertd due to the eausa(e) slsted. (Signahue and Title)
<br />Richard Fruehling, MD
<br />STATE
<br />ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />'�' � �
<br />�
<br />p 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAI
<br />�a�
<br />� 24e: On Nre basta of examinaUon aiM/or tmeatl8atlon. U rtry opfnlon deatfi occumed at
<br />�� the tlma. date artd Piace atM due to tlre causels) aFated. (Slgnature aml TIUe)
<br />� g
<br />YES IXI NO I I PROBABLY �I UNKNOVYN I fl YE3 fX� NO
<br />. ..__...._.-.__. _. �.... ..�... . ...... . . .,.. ......r.. .... .....,�. .
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />a. REGISTRAR'S SIGNATURE /ly. :I �`
<br />L ,Y)�.y/L��
<br />,�1�I �� /
<br />y
<br />H28a Is NO �J YES �J NO
<br />i or Prirrt
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />November 29, 2011
<br />OR CORONER CONTACTEDI
<br />❑ YES � NO
<br />c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES � NO
<br />d. WERE AUTOPSY FWDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH7
<br />❑ ves p No
<br />eonsWetlon aite, atc. (Speeify)
<br />
|