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201305914
<br /> STATE OF NEBRASKA
<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 NEBR4SKA'I.EPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'.S/1TA).RECOOS,,'; '
<br /> 7 y
<br /> d
<br /> DATE OF ISSUANCE
<br /> 02/26/2013
<br /> STANLEY'S,COOPER . .,1 ,
<br /> n:ASSISFANT S7ATEREGtS7'R.4'a.
<br /> -;-DEPARTMENT OF HEALTH:MO
<br /> LINCOLN,NEBRASKA ,=H(;IMAN•'5'ERVICES,';- r•','--
<br /> STATE OF NEBRASKA•DEPARTMENT OF HEALTH AND HUMAN SERVIDES°•.'; • ..-"`.,..,, 13 00799
<br /> CERTIFICATE OF DEATH ' _':,„'-, r,l,<.:. ."
<br /> 1.DECEDENT'S-NAME(First, Middle, Last, Suffix) 2.SEX • 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Donald Leroy Hadenfeldt Male • ' February 18,2013
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Grand Island,Nebraska 72 I March 15,1940
<br /> 7.SOCIAL SECURITY.NLlMaco 8a.PLACE OF DEATH
<br /> HOSPITAL ❑Inpatient OTHER ®Nursing Home/LTC ❑Hospice Facility
<br /> 8b.FACILITY-NAME(If not Institution,give street and number) ❑ER/Outpatient ❑Decedent's Home
<br /> IX
<br /> . I- Good Samaritan Society-Wood River ❑DOA ❑Other(Specify)
<br /> Ui 8c.CITY OR TOWN OF DEATH(Include Zip Code) 8d.COUNTY OF DEATH
<br /> cc
<br /> S Wood River 68883 I Hall
<br /> J 9a.RESIDENCE-STATE 9b.COUNTY Sc.CITY OR TOWN
<br /> Ili Nebraska I Hall I Cairo
<br /> LL9d.STREET AND NUMBER 9e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> • 206 West Syria ( I 68824 I ®YES ❑ NO
<br /> s
<br /> o 10a.MARITAL STATUS AT TIME OF DEATH❑Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> m
<br /> w ❑Married,but separated ®Widowed ❑Divorced ❑Unknown Florence M Melhorn
<br /> v
<br /> • 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> d Harvey W Hadenfeldt Vivian M Van Winkle
<br /> 1 13.EVER IN U.S.ARMED FORCES?Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> u (Yes,No,or Unk.)No Jeffery Hadenfeldt Son
<br /> 2 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> 2 ❑Burial ❑Donation Tracey Dietz 1328 February 22,2013
<br /> ®Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Apfel Funeral Home,1123 W.2nd,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 18.PART I.Enter the chain of events--diseases,injuries,or complications-that directly caused the death.DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional lines if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)Pancreatic Cancer 12 Months
<br /> disease or condition resuiting
<br /> In death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,it b)
<br /> any,leading to the cause listed
<br /> on Tine a. DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or injury that Initiated
<br /> the events resulting in death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> i
<br /> 18.PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19.WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ❑YES ®NO
<br /> cc
<br /> W 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURYI21c.WAS AN AUTOPSY PERFORMED?
<br /> ti
<br /> li ❑Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator
<br /> U Pregnant at time of death ❑Passenger ❑ YES ® NO
<br /> ❑ ❑Accident ❑Pending investigation
<br /> 5 ❑Not pregnant,but pregnant within 42 days of death ❑Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> Suicide Could not be determined
<br /> • ❑Not pregnant,but pregnant 43 days tot year before death ❑ ❑ ❑Other(Specify) TO COMPLETE CAUSE OF DEATH?
<br /> d ❑Unknown if pregnant within the past year ❑ YES ❑ NO 1 O-
<br /> E 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)
<br /> o
<br /> uu
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> h
<br /> ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) Z y 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> ' .w I February 18,2013 1 S
<br /> ° r
<br /> m W J 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH I v a a J 124c.PRONOUNCED DEAD(Mo.,Day,Yr.)I 24d.TIME PRONOUNCED DEAD
<br /> C 5 I February 19,2013 I 12:20 AM o
<br /> 2 ¢0 23d.To the best of my knowledge,death occurred at the time,date and place "w O 24e.On the basis of examination antl/or Investigation,in my opinion death occurred at
<br /> 0 o and due to the cause(s)stated.(Signature and Title) 0=O O I the time,date and place and due to the causes)stated.(Signature and Title)
<br /> f 1 Gary Settje,MD o 8
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> n YES 0 NO n PROBABLY n UNKNOWN ❑YES ®NO I Not Applicable If 26a is NO ❑YES ❑NO
<br /> .27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print
<br /> Gary Settje,MD,2116 W Faidley#400,Box 9802,Grand Island,Nebraska,68803
<br /> 28a.REGISTRAR'S SIGNATURE jej- r..__ 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> �� February 22,2013
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