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1.DECEDENTS•NAME (First, Middle,; Last; Suffix)
<br />Phillip Ray Hinrichs
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH . Dry, Yr.)
<br />August 16, 2012
<br />8. DATE OF BIRTH. (Mo., Dry, Yr.)
<br />October 2, 1948
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE•Last Birthday
<br />(Mrs.)
<br />63
<br />It UNDER 1 YEAR
<br />5c. UNDER 1' DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506 - 68 -1753
<br />8a. PLACE OF DEATH
<br />H032ITAL: ®opattent O ER: 0 Nursing Home/LTC ❑ Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Other(Speclly)
<br />Bb. FACILITY-NAME (If not institution, give street and number)
<br />VA Medical Center
<br />8c. CITY OR TOWN OF DEATH. (Include Zq. Code) :
<br />Grand Island 68801
<br />64. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Cairo
<br />9d. STREET AND NUMBER
<br />615 ''S S. High St.
<br />9e. APT. NO
<br />9f: ZIP CODE
<br />68824
<br />90. INSIDE CITY LIMITS
<br />511 YES ❑ NO
<br />10a. MARITAL. STATUS AT TIME OF DEATH :a Married ❑ Never Married
<br />D Harriet'. but sepamud O Widowed ❑ Divorced ❑Unknown :
<br />10b: NAME OF SPOUSE ( First,. Middle, Last, Suffix) If "Ate, g maiden name.
<br />Gayle Hall
<br />11. FATHER'S,NAME (First,.. I :. /Addle, LasI, Suffix)
<br />Wilbur Hinrichs
<br />- 12. MOTHER'S -NAME (First, Middle, Maiden Surlame)
<br />Luella Wolfe
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service if yes.
<br />(Yes. no, orank.)yea 09/17/68- 09/16/74
<br />14a. INFORMANTNAME
<br />Gayle Hinrichs
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METH00 OF DISPOSITION
<br />CI Burial ❑Donation
<br />7A Crematon ❑ Entombment,
<br />❑ Removal ❑ Omer(Specify)
<br />16a. EMBALMER- SIGNATURE :
<br />Not embalmed
<br />18b. LICENSE NO.
<br />18c.DATE (Mo.,IDay, Yr. ) *
<br />August 17. 2012
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION : CITY ' STATE
<br />Westlawn Memorial Park Crematory Grand Island,, NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or.TovA, State)
<br />i 1t.: on- ondermann Funer =1 Home 601 N. Webb Rd Grand Island NE
<br />18. PART 1 Enter the cnaln 01evama.- dleaesss, Injuries, or complications -that directly caused the death.: DO NOT enter terminal events such as cardlec arrest, APPROXIMATE
<br />respiratory onset, or ventricular hbriaetan without allowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line Add additional Tines if necessary 1
<br />IMMEDIATE CAUSE: I ones!
<br />BNIEDIATE.CAUSE (a) Q----Z 0 ' ` ThWan r‘ '' el\\, I.r `L
<br />1711.21p Cods
<br />68803
<br />INTERVAL
<br />to death
<br />(Anal
<br />dye,,, or eondMlom '. DUE T0, OR AS A CONSEOUENCE OF: I onset o death
<br />In death) A I
<br />(b)A to �tc e6 •1 k e �c'O e W r % &fl i sib
<br />aella„tq.e,„„.co..,
<br />if any, medley to the aua DUE TO, OR AS A CO E OUENCE OF: i onset to dsadl
<br />listed ongnea. I
<br />EafardrDNDERLYNG (0)
<br />CAUSE Osseo orin)ury UI I DUE TO, OR AS A coeseoUENCE OF: I onset b death
<br />Mined ter eventstera9ng
<br />In death) LAST
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS•Condhons contributing to the deem but not resulting In the underlying cause glven PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />20. IF PL�MAL E:
<br />0 Not pregnant within past year
<br />0 Pregnant .1 lime of dean :
<br />21a. MANNER OF DEATH
<br />'Nature! 0 Homicide
<br />❑ Accident❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />2111. IF TRANSPORTATION INJURY
<br />0 DrNadOperaor
<br />O wi Pas .r
<br />0 Pedeefdan
<br />❑ Ott (DP Y)
<br />:
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />�,2 dl
<br />Q YES ur
<br />O Not pregnant, but pregnant within 42 days of death
<br />0 Notpregnenl. but pregnant 43 days to t before death
<br />0 Unknown If pregnant within the put yew .
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE pAU OF DEATH?
<br />❑ YES N NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />r22c. PLACE OF INJURY-At home, farm, ,treat, factory, Wks building, IonatNCdon site, etc. (Specify
<br />y
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />' 22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY •: STREET 6 NUMBER, APT. NO:. CITYROWN STATE : ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />At tto erera
<br />24a. DATE SIGNED (IAo., Day, Yt.).
<br />240, TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mw, DAY, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />�bb SI ED Mo., 6ry, Y r)
<br />N i , ( "� (.st l`( c1a
<br />2 3e TIME OF DEATH
<br />�; 3.7 r3.<m
<br />C 29d. To the best of my ledge, death occurred at the time, date and place
<br />E and drat to t ) stated.:: (Signature and Dtle) y
<br />©.-:.y ... - ~ > / v
<br />' 4e. On the basis of examinaton:andbr Investigation, : in my opinion cheer *coned at
<br />E the tints. date and place and due to the cause(*) stated. (Signature and T le ) •
<br />25.010 .: CCO USE • • : • IBUTE TO DIE DEATH? 1 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO ❑' PROBABLY • . • O YES 4NO
<br />r28b. WAS CONSENT GRANTED?
<br />Nol Applicable k 26a 10 I10 CI YES ZiN0
<br />27. NAME, TITLE . D ADDRESS OF CERTIFIER Pe or Print)
<br />_
<br />11 ' r : \ :, r. ' 13 1
<br />28a. REGISTRAR'S SIGNATURE '
<br />I ll e,
<br />1), ..•.• a ®. ■ • a . . is Is
<br />P
<br />w
<br />It f.a le Vt.. . _ ; e ..
<br />28b. DATE FILED a B - f0.2 y Yr.)
<br />u GGi
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />08/28/2012
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201 305046
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH 12 26492
<br />HHS-61 Rev. 4/12 (550131)
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