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1.OECEDENT541AME (First,;; Middle, LW, Sufis► <
<br />Ann Marie Hinrichs"
<br />2. SEX
<br />Female
<br />:..2. DATE OF DEATH (Mo.,Day,Yr.)
<br />April 10, 2013
<br />t CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Leon, Iowa
<br />6. AGE -Lest Birthday
<br />(Yrs)
<br />70
<br />Ob. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />0. DATE OF BIRTH (Ma Day, Yr.)
<br />December 2, 1942
<br />NOS:
<br />DAYS
<br />HOURS
<br />MINS.
<br />T. SOCIAL. SECURITY NUMBER
<br />505 -54 -3971
<br />la. PLACE OF DEATH
<br />mammal; II IryWant
<br />C1HE&D►A••IngHome/LTC Hospice Facility
<br />: ❑ Decadent Nana
<br />❑ ab•rtswcar)
<br />❑ ER/Outpatient
<br />0 DOA
<br />Ib.:FACILITY-NAME (If not Institution, give street and number)
<br />Nebraska Medical Center
<br />ac. CITY OR TOWN OF DEATH (lnclud.2ip Cods)
<br />Omaha 68198
<br />ed. COUNTY OF DEATH
<br />Douglas
<br />ea.:RESIDENCE-STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Id. STREET AND NUMBER
<br />2219 Woodridge Lane
<br />1.. APT. NO,
<br />Sf. ZIP CODE
<br />68801
<br />Dy INSIDE CITY UMWTS
<br />@]( Yes ❑ No
<br />10., MARITAL STATUS AT TIME OF DEATH '_al Mad.d: ❑ Never Mant.d
<br />0 Married, but 'operated 0 Wlkowed 0 Divorced 0 UNaowe
<br />10b. NAME OF SPOUSE (First, NIddle, Last, SuRax),If wife, give maiden name.
<br />Marl Hin
<br />11. FATHEWE -KAME (First, < Middle, - Let, Suffix)
<br />Elmer Lamphiear
<br />12. MOTHER'.SNAME (First, Middle. Madan Surname)
<br />Oleta Made Higday
<br />13. EVER IN U.S. ARMED FORCES? OIva dab. of Senke H Y.0.
<br />(Yee, No, or link.) I NO
<br />14a. INFORMANT.NAME
<br />Marlin Hinrichs
<br />: 1eb. RELATIONSHIP TO DECEDENT :.'.
<br />Spouse
<br />10. ME111013 OF DISPOSITION
<br />Maude phonation
<br />a cs ❑Feteelheiee
<br />❑ p.rlM
<br />111a. EMBALMER titre LI
<br />I � "t Li
<br />tic. DATE (Mo.. Day, Yr.)
<br />April 15, 2013
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOON STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />Code
<br />` 68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. n I. Inter the .h6Ynt , 0- ours...INS .., et eomorc.eawar essay s a es wet. DONOT
<br />e.pbabry owe. or Ya.akula5b6MI.nwlhautshowing the sealed). 0 Nor Aem onard. only nn ears.
<br />IM MEDIATE C f
<br />IMMEDIATE CAUSE (r ( r { 1 1 �'r�/� 7 ! /� /' ((
<br />disease gCOndltlon remitting a) rte �•{1' \O,J l i .T'LVl I I / 4.r rt-.�) r I! ?I }/( � '
<br />in death)
<br />«,w wr.rd morel such ammo arar APPROXIMATE INTERVAL
<br />.0. e(... Add .dde.na line e n.er..Y.
<br />Orion to dyer
<br />yep fl I j j • '
<br />./)/`/ 1/) �k) 11111
<br />DUE TO.OR:AS A CONSEQUENCE OF +:/'}� onset to death
<br />Sequentially list conditions If ay, leading to Uleuass i.ad b) C U I.: +4.^+ /✓ O b ), S 0 ....
<br />anon. a' DUET°, OR AN A CONSEQUENCE OF: - onset ettt tto death
<br />Enter the UNDERLYING CAUSE . c) L i I llll - \\ ' )/�) Y
<br />1111 � & �f/^1 1� t ,Ol
<br />(d...... orinpry that Initiated
<br />th events r.sutitnp in death) DUE TO,OR AE A: CON SEQUENCE OF:
<br />:
<br />LAST
<br />onset to death
<br />10. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions eaeWutlng to de death but not n liking a the underlying came given le FART L
<br />16. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES a �C�
<br />,,, 220.0. IF FEMALE
<br />g N at pregnant wthin pan year
<br />Prsgnaft at Wes of death :
<br />❑ Not pregnant. but pregnant within 42 dye et death
<br />❑Not prsg ant,: pwMnnt43 days to 1 year before death
<br />❑Unknown I pregnant within the past year
<br />21) MANNER OF DEATH
<br />Jyl Rotund ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be date ntln.d
<br />21b. IF TRANSPORTATON INJURY
<br />❑ Driver/Operator
<br />: ❑ Passenger
<br />❑ P.desMm
<br />❑ Other lop•d')
<br />21c. WAS AN AUTOPSYP ED?
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ ND
<br />228 OATS OF INJURY (Mo.. D.Y. Yr.)
<br />220. TIME OF INJURY .
<br />m
<br />22c. PLACE OF INJURY.At home, Tan, sh.51, factory, °Mee bulking, conehuetion Iie, .le. (Sp.cly) -..
<br />220. INJURY AT
<br />❑YES 0 N
<br />ate. DESCRIBE HOW INJURY OCCURRED
<br />YIL. LOCATION OF INJURY - . STREET : & NUMBER. APT. NO. CITY/TOWN STAN! ZIP CODE
<br />rt
<br />$�
<br />i
<br />t) :
<br />o
<br />23s. DATE
<br />4
<br />oe, Yr.) (M
<br />? 10 , (3 1
<br />O tt
<br />I :EC
<br />Ea
<br />0 I.
<br />2 $
<br />orc
<br />2e(. DATE SIGNED (MO., Day, Yr.)
<br />2eb. TIME OF DEATH
<br />m
<br />2e(.. PRONOUNCED DEAD (M0., Oay, Yr.)
<br />24d. T1ME PRONOUNCED DEAD
<br />m
<br />D SIGNED (Moe, Day Yr.! /� 22c. TIME !� OP DEATH
<br />L I6 aOL3 61710 P m
<br />24e. On the asks n b sxandnadon and/or bwssdgadon, k my opinion death occurred
<br />date id place and due to the cause(*) stated. (Signature and Title)
<br />at Si. the a
<br />27d Iha rimy •
<br />and • to I s • a)
<br />.dgs ° a blase, dale and place
<br />% and )
<br />Vile
<br />..DID USE CONIRI •a
<br />S ❑. NO ❑ - � •
<br />TO THE D TH7 "
<br />Y : ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISS 710N BEEN CONSIDERED?
<br />❑ YES J^' \'o
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable 1125. Is NO ❑ YES ❑ NO
<br />• NAME, TITLE: AND . ERT1aER (Type Or Print)
<br />Rudy Lackner, 'M.6.;982315 NE Medical Center Omaha, > NE 68198 -2315
<br />26a REGISTRAR'S SIGNATURE !
<br />M.., Der, Yr.)
<br />260. � l wartime 2013
<br />•
<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 />05/13/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201307578
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />E FRTIFICATF<fl HEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />13 23088
<br />
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