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1. DECEDENT - NAME FIRST MIDDLE LAST Melvin Harold Ruge 2 SEX Male 3 DATE OF DEATH /Month. Day Year) November 20, 2002 4. CITY AND STATE OF BIRTH Ill not in USA.. name country/ St. Libory, Nebraska 5a. AGE - Last Birthday )Osl 80 UNDER 1 YEAR UNDER 1 DAY 6 DATE OF BIRTH (Month. Day Feed December 1, 1921 5b MOS I DAYS 5c. HOURS • MINS 7 SOCIAL SECURTIY NUMBER 508 -18 -5067 8a. PLACE OF DEATH HOSPITAL: Bs Inpatient OTHER: [] ER Outpatient ■ DOA Nursing Home Residence Other (Specify; 8b. FACILITY - Name (If not Institution, give Street and number) St. Francis Medical Center 28a. DATE SIGNED (Mo.. Day Yr / Bc. CITY. TOWN OR LOCATION OF DEATH Grand island 8d. INSIDE CITY LIMITS Yes IA No In Be. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER /Including Zip Code) 68801 2426 Commerce Ave. OO he INSIDE CITY LIMITS Yes © No 10. RACE - (e.g., White. Black. American Indian. etc.) ISoe ` it e 11. ANCESTRY le.g.. Italian. Mexican, German, etc/ (Specify) American 12. A v MARRIED ❑ WIDOWED NEVER DIVORCED ■ MA - I , 13. NAME OF SPOUSE (If wife. give ma den name) Eleanor Luebs 14a. USUAL OCCUPATION lave kind of work done during most of working life, even (retired! Farmer 14b. KIND OF BUSINESS INDUSTRY Agriculture 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary I0-12) College 11 -4 0 5 12 16. FATHER - NAME FIRST MIDDLE LAST • John Ruge 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Martha Hinerichs 18. WAS DECEASED or EVER IN U. S. ARMED FORCES? IIfVe- 15 war 1942 2 -1946 19a. INFORMANT - NAME Eleanor Ruge OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART C O " e-G col.) r^ c...6...., t. / PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 -54) Yes f] No 24 AUTOPSY )(' Yes n No IV 25. WAS CASE REFERRED TO MEDICAL Y EXAMINER OR CORONER Yes n No 11/I 26a. II Accident . Undetermmed . Suicide III Pending Ill Homicide Investigation 26b. DATE OF INJURY (Mo.. Day. Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e. INJURY AT WORK Yes No ❑ 26f. PLACE OF INJURY - At home. farm. street. factory office building. etc. (Specify) 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE To be Completed by Attending PHYSICIAN ONLY 27a. DATE OF DEATH (Mo.. Day Yr.) November 20, 2002 To be Completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day Yr / 28b. TIME OF DEATH M 27b. DATE SIGNED (Mo.. Day. Yr.) November 21, 2002 27c. TIME OF DEATH 4:25 p 28c. PRONOUNCED DEAD (Ma. Day, Yr/ 28d. PRONOUNCED DEAD (Hour/ M 27d. To the best 01 my knowledge. death occurred at t e time, date and place and due to the ® cause(s) stated. ^ e..1,„.,4.(0 (Signature and Title) 14 / - 1 `" 28e. On the basis of examination and for investigation, in my opinion death occurred at the time. date and place and due to the causels stated. r (Signature and Title) 14 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES NO n UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? YES X NO 30b WAS CONSENT GRANTED? YES NO WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD:ONF1LE -WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS,SECTION, WHICHIS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE NOV 2 7 2002 LINCOLN, NEBRASKA 20 EMBALMER - SIGNATURE 8 L CENSE NO 7 rl�tQ�l - l 22a. FUNERAL HOME - NAME Apfel- Butler- Geddes 21a METHOD OF DISPOSITION ❑ Burial Removal ® Cremation Donation 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 21b. DATE Nov. 23, 2002 Gi 19b. INFORMANT MAILING ADDRESS 2426 Commerce Ave., Grand Island, NE. 68801 23. IMMEDIATE CAUSE PART la) Ces' 5/-0 - ' G.. 4 c,• -tF- DUE TO, OR AS A CONSEQUENCE OF (b) (c) DUE TO, OR AS A CONSEQUENCE, OF: 201.4069 ASSISTANT ATE EGIS HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH ;)MAN SERVICES ESFINANCE AND.:SUPPS)RT 02 13565 VITAL STATISTIa CERTIFICATE OF DEATH (STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP) (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (c)) 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) Daniel Cronk M.D. 08 N. Howard, Grand Island, NE. 68803 A / 21c. CEMETERY OR CREMATORY NAME Central NE Cremation 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE bbon, Nebraska 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR IMo. Day. Yr.) NOV 262002 Interval between onset and death Interval between onset and Interval between onset and death