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STATE OF NEBRASKA
<br />.a :�!� F
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEACTH ��tD H ��SE��/ICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILF WITH THE NEBRASK�4 DL�Q:SY2T��YIJ��T D�W�E�LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR I<IT� �E�Qh��.'' ••. ',; ,�
<br />j • y�,.� g � � �J ,d• " �� y
<br />t.
<br />DATE OF ISSUANCE �� ;�� r�
<br />03/21 /2011 Sr4n�i.FY S. „�ppr�E� -, �� y �
<br />2 012 0 4 4 5� ,�5��� r��,���� �� ;
<br />DEP�AR�`FIEIUT i�P HEALTN AND� ; -
<br />LINCOLN, NEBRASKA HUMA ° �WSS�l�4fTCES• ! �. ,� ° ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�ES� 4 �'�; �.,f �• �_ti 11 00892
<br />�.�R� �rwH� � �r urr�� n ' � w ; .irR, _� :.�; , . .,_
<br />1. DECEDENI'S•NAME (Firat, Middle, last, Sufti�c) 2. SDC `= s 3. DATE OF D_E'ATH (Mo., Day, Yr.)
<br />Joyce Nadine Engel Female �_March 9, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Blrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'►$•) MOS. DAYS HOURS IWNS.
<br />Doniphan, Nebraska 83 July 17, 1927
<br />7. SOCIAL SECURIT1f NUMBER 8a. PLACE OF DEATH
<br />506-2&3409 OSH PRAL ❑ Inpatle�rt OTHER ❑ Nursing HomelLTC � Hospice Fac11Hy
<br />Bb. FACILITY•NAME (H rtot IretltuUOn, give street artd number) � ER/Outpatlerrt ❑ DecedeM'e Home
<br />�
<br />� Saint Francis Medipl Center ❑ ooa ❑ Other (Specffy)
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Doniphan
<br />LL 8d. STREET AND NUMBER 98. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY UMITS
<br />�, 3510 W. Le in Road 68832 ❑ vES � No
<br />� 10a. M1AARITAI. STATUS AT TIME OF DEATH � Married ❑ Never Marrl�! 10b. NAME OF SPOUSE (Flrat, Middle, Last, Suffix) If wHe, give malden name
<br />� p n�M�a but separated ❑ �nneowaa ❑ ni�o��ea ❑ u��ow� Louis Engel
<br />� 71. FATHER'3•NAME (Fhst, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />John Stonehocker . Mildred Hockenberry
<br />°' 19. EVER IN U.S. ARMED FORCES? GNe dates ot service NYes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �Y�, No, or Unk.) No Louis Engel Husband
<br />,� 15. METHOD OF DISPOSRION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ Dormdon
<br />Tracey Die1z 1328 March 12, 2011
<br />❑ Crematlon � F�MmbmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOVYN STATE
<br />❑ Removal ❑ Other (SP�K3+1
<br />Cedarview Cemetery Donfphan Nebraska
<br />77a. FUNERAL HOME NAME /WD MAILINO ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Istand, Nebraska 68801
<br />CA SE O DEATH See nstructions and exam es
<br />1& PART 1. EMer the chaln W everrt�dlsaases, InJurlee, or eomplimtion�that dlrectly cauaed the death. DO NOT e�rter tarminsl eveMS euch as cardiac aneat, ; APPROXIMATE INTERYAL
<br />�eapiratory arteet, orveMricular flbNllatlon wiMOUt showing ttre atlology. DO NOT ABBREVIA7E. EMer only one cauae on e Ifne. Add add(donal Urrea N naeaesary. i
<br />IMMEDIATE CAUSE: ; onset to death '
<br />�m�oure cause � e) Acute Cerebral Vascular Accident ; Hours �,^
<br />alaease cr coeatpa, res�,ktng �.
<br />� d �� DUE TO, OR AS A CONSEQUENCE OF: ; onaet to death
<br />Sequerrtlally Ilat tonditlo�re, H b) Hypertension ; Decades
<br />enY� Ieadie8 ro tlre catree Iiated �
<br />on Ilne a DUE TO, OR AS A CONSEQUENCE OF: 0 ortset to death
<br />Enmrnre unroEw.nNa causE �)
<br />(disease or in}ury tliaz IniBamd
<br />tne evenm resmnna tn dearn� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />� d)
<br />18. PART n. OTHER SIGNIFlCANT CONDITIONS-Condttlo� eontrlbutt� to the death but rrot resuftlng In the underlying puse gtven in PART 1. 19. WAS MEDICAL EXANONER
<br />OR CORONER CONTACTED7
<br />a , ❑ YES � NO
<br />W D. IF FEMALE: 21a MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21a WAS AN AUTOPSY PERFORII�D?
<br />�
<br />� � Not pregrtaiR wIGUn paet year � Natural � HomlWde � Drtver/Operetor �� � NO
<br />V ❑ P�� � � °f d� � Aedde�R � Penqln9 Imesllgatlon ❑ �
<br />� Not pregnant, but pregna�n wlthin 42 days aT death � Pedestrian 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� � NM pregnaM, but piegnaM 49 days to 7 yeer before death ❑���� ❑ Coutd not be demrm��ed �� (S�ryl TO COMPLETE CAUSE OF DEATH?
<br />'� ❑ unwwm rc piegnene wehin me psst rear
<br />❑ res ❑ No
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, faetory, office buildl�, constructlon site, ete. (Specify)
<br />8
<br />.� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�-
<br />❑ YES ❑ NO
<br />5'
<br />22l. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� March 9, 2011 � � �
<br />g �� 23b. DATE SIGNED (MO., Day, Yr.) 23e. TIME OF DEATH � k 24c. PRONOUNCED DEAD (MO„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />° � March 17, 2011 08:33 AM � 6 a�
<br />$� � . To the best M my Imowtedee, deafh oaurted at the dme. data enE place � � 24e. On the basla M examinatlon arM/or ImesdBavon. in mY oWnlon tleath oaurted at
<br />o� and tlue to tlre eause(s) smted. (Slgnature and Tkle) o�� Ne tlme. Oale and piace and due W the musefe) etated. (Signature and Title)
<br />�
<br />~ Kenneth Vettel, MD '" � s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEDI
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable (f 28a Is NO ❑ YE3 ❑ NO
<br />2. , TITL D OF RT (P YSIC , C I T T, C R R PHY C ORNE1� (Type or PriM)
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'3 SIGNATURE �+ � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />March 17, 2011
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