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To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Oscar Axel Sorgenfrei 2. SEX •?13. Male }DATE 9F= DEATW'(Mo., Day, Yr.) , Ji)ne,22 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 18, 1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -3430 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 ad. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 417 E. 19th St. 9e. APT. NO. 9f. ZIP CODE 68801 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 Harriet Fae Schwieger 11. FATHER'S -NAME (First, Middle, Last, Suffix) Oscar Sorgenfrei 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Petzoldt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 07/02/1951- 06/11/1953 14a. INFORMANT -NAME Harriet Sorgenfrei 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) June 28, 2010 tad. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I 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 48 Hours respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 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, it b)Squamous Cell Lung Cancer 6 Months 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) •° PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Ling Disease ,pneumonia,dementia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ij NO IF FEMALE: El Not pregnant within past year 0 Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death J 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 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 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Ma., Day, Yr.) June 22, 2010 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.) June 24, 2010 I 23c. TIME OF DEATH 11:59 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Ryan D. Crouch, DO 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 ❑ YES ISSUE DONATION BEEN CONSIDERED? 17 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, YSICIAN ASS ISTANT COR • NEWS PHYSICIAN OR COUNTY A Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 ORNEY) (Type or Print) 128a. REGISTRAR'S SIGNATURE A /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I June 25, 2010 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND - JIrL4N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA .13Ek MFMQF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL �bS _ (, a DATE OF ISSUANCE 06/29/2010 LINCOLN, NEBRASKA STATE OF NEBRASKA 201401341 201008798 STA Y S COOPER A�,S4T.ANTrSTTE $EGISTRAI j DEPARTME)0 OkIlEALT.H AlNFLS= ,o.• HUMAq$ERVICES`- STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE . ; y CERTIFICATE OF DEATH • •.r?�; 10 01758 w it ]. t. ..= .mow