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STATE OF NEBRASKA
<br />�„
<br />WHEN THIS COPY CARRIES THE R,4ISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH �AI�T3 H'CiN�'A�V ��E�2VI�ES,1T CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASlCA' D�P�I�R�M�N'T OF i-D tTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI7"ORY FOR V�"T�; I�EC�,�O y '4 .. ,���
<br />. � �
<br />DATE OF ISSUANCE � r ,,, . 6 �, C� ,. � a
<br />03/21 /2012 2 012 0 3 5 0� �r;��r�� s. ;�-��PSER - '� a� �`,
<br />ASSIS=TANT �ATE l��'GtS�TRAR � ' ',:�
<br />D�Pa4f��.M,ENT 0� HEALTH�AND-,_ � +°
<br />LINCOLN, NEBRASKA HUIk�J, ,,e ;: ,'"`� `
<br />,, �� .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC� �'�`� � f!�i' `' r ' �'1� � 00982
<br />/'►C�TIC1/�ATL� AL� 11CATLJ � --.4'S? "•' �
<br />� VVn�n vVn��■ , • ...a. f�
<br />1. ECEDENTS-NAMB (First, Middle, Laet, SuHlrz) 2. SIX !� ,3. DATB OF DEATFI (Mo., Day, Yr.)
<br />lorence Marie Hadenfeldt Female � � Marcli 2012
<br />4. CI7Y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last BlRhday b. UNDER 1 YEAR Be. UNDER 1 DAY 6. DATE OF BIRTH (Mo„ Day, Yr.)
<br />(YB•) MOS. DAYS HOURS MINS.
<br />Grand Istand, Nebraska 71 June 22, 1940
<br />7. $OCWL SECURITY NUMBER 8a. PLACE OF DFATH
<br />507-44-2341 OSH piTAl. � Inpatlent OTHER ❑ Nursing Home/LTC � Hosplee Faeillty
<br />Bb., FACILIT1f•NAME (N rwt Inst(tution, glve street and aumber) � ERIOutpaUen! ❑ DeeedaM'e Home
<br />�
<br />� $aint Francis Medical Center ❑ �A ❑ �''�Sp���
<br />� Bc: CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />c IGrand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Cairo
<br />� 9d. STREET AND NUMBER . APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMRfS
<br />�` 206 W. S a 68824 � res ❑ No
<br />� 10a. MARITAL STATU3 AT 17ME OF DEATH � Marrled � Never Marrled 106. NAME OF SPOUSE (Flret, Middle, Lask SuR6c) H wife, gtve malden mme
<br />� �] n�arried, nut separated ❑ Inndowea ❑ nnrorced ❑ unknown Donald Hadenfeldt
<br />� 11.' FATHER'3-NAME (Flrat, Middle, Last, Suftix) 12. MQTHER'S�NAME (Firat, Middle, Malden Sumame)
<br />d Warren W Melhom Florence M Heard-Wadge
<br />�' 13: EVER IN US. ARMED FORCES4 GWe dates of servles H Yea. 14a. MFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �rea, No, or unk.) No Donald Hadenfeldt Spouse
<br />, 19: METHOD OF DISPOSITION 76a. EMBALMERSIGNATURE 18b. UCENSE NO. 78e. DA7E (Mo, Day, YrJ
<br />�°- � B° '�� � Tracey Dietz 1328 March 20, 2012
<br />� CremaUOn � FrrtombmeM �� CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Spacffy) �ntral Nebraska CremaUon Servlces Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS {Street, Clty or Town, 3tate) 17b. Zip Code
<br />�4pfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />A SE OF DEAT See instruct ons and e�cam es
<br />18. pART 1. FrAer Ure chaln of eva�-0isaases, Injudee, or eompllradone�that dlrectiy caused the death. DO NOT e�rter tertNnal eve�Ua such ae CeNiac artest, � APpROXIMATE INTERVAL
<br />' resplraWry amast, or veMricutar flbriltatlon wRhout showl� ihe etlotogy. DO NOT ABBREVWTE. F�nter oniy o�re muee on a Wre. Add edditlonel �nea H�ry.
<br />re
<br />IMMEDIATE CAUSE: = or�set W death
<br />IAAMWIATECAUSE(FUmI a)Hypotensive Shock ; 5 Hours
<br />dlgease ot eonditlon reeultlng i
<br />10 d �'� DUE TO, OR AS A CONSEQUENCE OF: � ur�et to death
<br />Sequentially Ilst condWo�re, It b) Diabetes : Years
<br />arry, leading to tha ceuse Iletetl =
<br />on Ilrre a. DUE TO, OR AS A CONSEQUENCE OF: ; o�vet to death
<br />E�ter the UNDERLYINO CAUSE �� �
<br />(dieea� or Ujury thst In8latetl �
<br />ure e�eme res�,mne m aearnl DUE TO, OR AS A CONSEqUENCE OF: : onset to death
<br />'asr d) ;
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS-Co�Mitlons Contributl� to the death but rrot resultlng in the umierfying puBe glvan In PART 1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W O. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPpRTAT10N INJU 21c. WAS AN AUTOPSY PERFORMED7
<br />F � Not PreBnant within past year � Natural � Homlcide � DMedOPersMr
<br />,�,� aree�e at ume m aeaeh ��� ❑ YES � No
<br />V � � Acddent � Pe�Min8lmestl9ation
<br />� ryot pregm.W, yut pregna�rt wlNln 42 days of death � PedeaMan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />a � eulydde � CoWd not be Aetermhred TO COMPLETE CAUSE OF DEATH7
<br />� Not P�B�errt, but P�eB�M 0.9 daye to 1 year before deatfi � Otlrer (SPecItY) � YES ❑ NO
<br />� ❑ Unlmown H preg�mnt withln the past year
<br />E 228. DATE OF INJURY (Mo., Day, Yr.) 22b. TIMH OF INJURY 22e. PLACE OF INJURY-At home, tarm, atraet, factory, oHice bullding, ca�tructlon site, etc. (SpeeHy)
<br />$ '
<br />� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />I�-
<br />, ❑ vES ❑ No
<br />22f. LOCATION OF INJURY • STREhT & NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� March 14, 2012 B � �
<br />� � 23b. DATE SIGNED (Mo„ Day, Yr.) 23e. TIME OF DEATH � k Y 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />o March 16, 2012 05:49 PM � gg?? <�
<br />To the 6es! Of my Imowledge. death occurted at the tlrt�. data and Plece $ p 5 �
<br />24e. On Me b�ls ot esemllnaUon enNor Inreetlgatlon, ln my oplNOn death ocwrted at
<br />� aea aue co ene eauae(el sta0ea. (s�e�ewra ena rwe) 8 Q the tlme. date a�M plaoe and due to the eauae(e) stated. (S18�mture and TIUe)
<br />~ Kenneth Vettel, MD ~ g �
<br />25., DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YE9 � NO Not Applieable N 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND DRESS CERTIFIER (PHYSI , HY I 1 T, R N R S R A (Type or Nrrt)
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE �• � 28b. DATE FlLED BY REGISTRAR (Mo.. Day, Yr.)
<br />March 20, 2012
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