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r To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Dorothy Pauline Radke 2. SEX Female '' 3. DATE OF DEATH (Mo., Day, Yr.) July 8, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 88 5b. UNDER 1 YEAR 5c. UNDF 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 9, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -20 -4859 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zlp Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1719 N. Kruse Avenue 9e. APT, NO. I 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) If wife, give maiden name Paul Radke Sr 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred G Pleis 12. MOTHER'S -NAME (First, Middle, Malden Surname) Pauline Susanna Beck 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Paul Radke Jr 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 9, 2013 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 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death < 1 Week respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional fines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Dementia > 1 Year any, leading to the cause listed on line 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 H. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' . t resulting In the underlying cause given In PART I. Cerebral Vascular Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED'? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death o Not pregnant, but pregnant within 42 days of death ❑ 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 determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE b' W 2 E „ Y 2 i 23a. DATE OF DEATH (Mo., Day, Yr.) July 8, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 9, 2013 23c. TIME OF DEATH I 03:25 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD $ U 0 3d. To the best of my knowledge, death occurred at the time, date and place o S and due to the cause(a) stated. (Signature and Title) g Jennifer L. Brown, 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 (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, T Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE (/VJD{lJ�f/V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 10, 2013 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. d. DATE OF ISSUANCE 07/15/2013 STATE OF NEBRASKA 201306700 ASSISTANT SATE REGISTRAR DEPARTMEAtT'OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 13 02918