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STATE OF NEBRASKA • WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA QEPAR.TMENT OF HEALTH AND • HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL rzeo.14a., DATE OF ISSUANCE 02/22/2012 201305146 STAN ,EY s. ,CoOPEP ASSISTANT'STATE RLGIS17 AR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN- SERWCES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ;:' r' r CERTIFICATE OF DEATH • ;' =1t41 12 00541 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Ruth Mary Lautenschlager 2.[SEX Female S. DATE OF DEATH (Mo., Day,yr.) February 16, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Prosser, Nebraska 5a. AGE • Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 5c. UNDER 1 DAY :: 6. DATE OF BIRTH (Mo., Day, Yr.) August 18, 1924 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 332 -20 -4081 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE•TATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3936 Meadow Way Trail 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name Harold D Lautenschlager 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ernest W Berg 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Einspahr 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Harold D Lautenschlager 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 17, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 1 CAUSE OF DEATH (See instructions and examples) 1e. PART 1. Enter the chain of events -- diseases, injuries, or complicatlona4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 1 Day respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessa.y. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Myocardial Infarction disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, it b) any, leading to the cause listed on cane a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C ) (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: 1 ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death I ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) [22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .t FS E o EI 23a. DATE OF DEATH (Mo., Day, Yr.) February 16, 2012 i; 3 i r g ° < w z 8 W O E ~ u s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (MO., Day, Yr. F ebruary 17, 2012 23c. TIME OF DEATH I 11:10 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD o < 0 3d. To the best of my knowledge, death occurred at the time, date and place E u and due to the cause(e) stated. (Signature and Title) '" 2 Donald Wirth, MD 24e. On the basis of examination and/or Investigation. In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, RRYSTCIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A'T• RNEY) (Type or Print) Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE A! 1� (� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 17, 2012 STATE OF NEBRASKA • WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA QEPAR.TMENT OF HEALTH AND • HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL rzeo.14a., DATE OF ISSUANCE 02/22/2012 201305146 STAN ,EY s. ,CoOPEP ASSISTANT'STATE RLGIS17 AR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN- SERWCES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ;:' r' r CERTIFICATE OF DEATH • ;' =1t41 12 00541