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1. DECEDENTS -NAME (First, Middle, Last, Sufllx)
<br />Margaret Louise Rauch
<br />201302966
<br />Et 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />H
<br />(Yes, No. or Unk.) No
<br />4. CITY AND STATE OR TERRITORY, OR FOR/SON COUNTRY OF BIRTH
<br />Norfolk, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />o 506 -36 -2160
<br />M. FACILITY -NAME (If not Institution, give street and number)
<br />o Nebraska Medical Center
<br />k. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 88198
<br />Sc. RESIDENCE -STATE
<br />LL
<br />Nebraska
<br />Sd. STREET AND NUMBER
<br />1720 West Oklahoma Avenue
<br />a
<br />a
<br />16. METHOD OF DISPOSITION
<br />❑Budd ❑Donation
<br />Men/nation ❑EntomWmnt
<br />❑Removal ❑Othsdspaclty)
<br />fm. AGE-Last Birthday
<br />(Yre.)
<br />77
<br />lib. COUNTY
<br />Hall
<br />15a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />lb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />CAUSE OF DEATH (See Instructions and examples)
<br />ti. PART I. Enter the chain a sreall - dlnoses, Mufti, or compllcNbns -Mat dbocIly cawed tin loth. DO NOT gM.r terminal swnb such as cardiac rest,
<br />respiratory rest, or ventricular BbrMalten without s awing the etiology. DO NOY ABBREVIATE. Enter only one mum on • gm. Add additional lime a nscnaary.
<br />IMMEDIATE CAUSE:
<br />a)
<br />a��(; a t it r yf f3 r p(.e f tt. A V 6 I oc,k
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />MINS.
<br />3. DATE OF DEATH (Mo.,Direet )
<br />April 29, 2010
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 14, 1932
<br />6s. PLACE OF DEATH
<br />)lOSPITA1 al Inpatient glum Nursing Home/LTC
<br />❑ ER/Outpatient
<br />❑ DOA
<br />❑ ec
<br />Dadent's Moms
<br />❑ °tB)»a er( y)
<br />❑ Hospice Facility
<br />t'rt 4 d s Oaf CtIe..4� oC6 t (✓" a b1 �fA , tiJ
<br />DUE TO, OR AS A CONSEQUENCE OF: I
<br />Ed. COUNTY OF DEATH
<br />Douglas
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />91. ZIP CODE
<br />88803
<br />10a, MARITAL STATUS AT TIME OF DEATH UO Married ❑ Never MenI lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wile, give maiden name.
<br />Married, Maed, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Fred W Rauch
<br />11. FATHERS-NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle. Maiden Surname)
<br />Hugh M Winchester Margaret Allen
<br />14, INFORMANT -NAME
<br />Fred Rauch
<br />16b. LICENSE NO.
<br />17.. FUNERAL HOME NAME AND MAIUNG ADDRESS {Street, City or Town, State)
<br />Heafey - Heafey- Hoffmann - Dworak & Cutler, 7805 W Center Road, Omaha, Nebraska
<br />9g. INSIDE CITY LIMITS
<br />Yes ❑ No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />ISC. DATE (Mo., Day, Yr.)
<br />April 29, 2010
<br />l Sd. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Heafey Heafey - Hoffmann - Dworak & Cutler Crematory
<br />CITY/TOWN
<br />Omaha
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68124
<br />IMMEDIATE CAUSE (Final
<br />disease or condleon resulting
<br />In death)
<br />APPROXIMATE INTERVAL
<br />onset to dealt
<br />z o(Q
<br />Sequentially list conditions, If
<br />any, leading to the cause Ibted
<br />on Ens a.
<br />onset to death
<br />2.y ea,
<br />Enter the UNDERLYING CAUSE c)
<br />6 4 efcv - a
<br />onset to death
<br />)ury that InIU
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />18. PART N. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART L
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown If pregnant within the past year
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22b. TIME OF INJURY
<br />m
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />21a. MANNER OF DEATH
<br />gestural ❑ Homicide
<br />❑ Accident ❑ Pending InvestIgation
<br />❑ SulcIds ❑ Could not bs detamtlned
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedashian
<br />❑ Other (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />16. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />El YES ❑ No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />YE ❑ NO
<br />ptefr rprdlrs
<br />22e. PLACE OF INJURY -At home, farm, street, factory, Mks building, construction site, etc. (Specify)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />m
<br />23a. DATE OF DEATH (Mo., ` ,,d
<br />syt Yr.) ' O zi
<br />23b. DATE S,ti y, Yr.) 23 TIME OF DEATH in O
<br />_ SKIED (Mo., Day, lo; m E D`z
<br />., ti, O , 23d. To e but of my knowledge, death occurred at the lime, dtf e tint ace - end due to the tmoecht) eta. gl .S a la.t1" :vr7al. ^ -. .u-14
<br />!r f 1 "C)n
<br />('o :4WApi'c 2c • &) / f' �t�
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26 IA8 ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />YES ❑ PROBABLY
<br />UNKNOWN ❑ YES 151, NO Not Applicable If 26a Is NO ❑ YES ❑ NO
<br />at
<br />27. NAME, TITLE AND ADDRESS CERTIFIER-IPHYSICI N, PHYSICIAN AS ISTANT, ORONER'B SIC NOR COU TY ATTORNEY) (Type or Print)
<br />,r tAf&vl MMMM '`tliA v cYst o ftial/iLr t�tef Cot c:ert irggii.90 (�Mt�.C4r. 9
<br />OF
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />2Sa. REGISTRAR'S B
<br />P...., �--� MAY 6 2010
<br />TRUE 077
<br />nom.
<br />JUN 18 2010:
<br />TICS, DOUGLAS
<br />OMAHA. NE
<br />,r I
<br />CO. hHEti,
<br />339195
<br />onset to death
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED n - 0
<br />A
<br />r t t ix) EAD ity
<br />24e. On the basis of examination and/of Investigation, In my opinion death occurred
<br />Ma tbrw data and oldest and due to Ma causa(s) stated. (Signature and Title)
<br />
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