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To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Cathy Lynn Bredthauer
<br />2. SEX ' '-
<br />Femal
<br />3. fkATE F 10EATPr Mo., Day, Yr.)
<br />Atlga) 24..`261.4,-
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />66
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY .'18
<br />i3ATE OF BIRTH (Molt'Day, Yr.)
<br />April 7, 1948
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -66 -0948
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />St. Francis Memorial Health Center LTC
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1912 Stolley Park Cir
<br />APT. NO.
<br />1
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />IN YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Larry Dale Bredthauer
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harold Barge
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elsie Rothfuss
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Larry Dale Bredthauer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />IX) Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />August 22, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER I
<br />18. PART I. Enter the chain of events - diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2001 -Death
<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:
<br />IMMEDIATE CAUSE (Final a) Ovarian Cancer - Malignant
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />Sequentially list conditions, If b) I
<br />any, leading to the cause listed
<br />1
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />Enter the UNDERLYING CAUSE c ) I
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) I
<br />I
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />ID Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />'II'
<br />Y rc r
<br />E ui
<br />23a. IMTE OF DEEA= (Mo., Day, Yr.)
<br />August 20, 2014
<br />124a.
<br />,;
<br />' r
<br />E da g
<br />W z
<br />B 0 0
<br />~ o a
<br />DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 21,2014
<br />I 23c. TIME OF DEATH
<br />11:55 PM
<br />24c. PRONOUNCED DEAD (MO., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />3 < O 3d. To the best of my knowledge, death occurred at the time, date and place
<br />.g a and due to the cause(s) stated. (Signature and Title)
<br />o
<br />'' 2 Richard Fruehling, MD
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cau e(6) stated. (Signature and Title)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehling, MD, 2116 W Faidley #400,
<br />Box 9802, Grand Island, Nebraska, 68803
<br />REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 22, 2014
<br />1 28a
<br />STATE OF NEBRASKA 201504'135
<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 VVIT4L - RE
<br />DATE OF ISSUANCE
<br />08/25/201 4
<br />LINCOLN, NEB
<br />STANLE� V,e00
<br />AS,0"I A11?T.9'TATE RE�IITRAR
<br />Nr.,
<br />©Evegl r Qr EALTH `AND
<br />NEBRASKA
<br />Hotly' SEIM
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERIOU
<br />CERTIFICATE OF DEATH
<br />14 04204
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