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1. (First, odds, Last. SWIM •••••• • • •• ••�•� • • •• •• • •• •,•• • • • •
<br />Dallas Malvere Frohling
<br />2. SEX
<br />Male
<br />2 DATE OF DEATH (M4.,Dsy,Yr.)
<br />May 31, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIM
<br />Campbell, Nebraska
<br />8e. AGE -Last Birthday
<br />(Yon)
<br />93
<br />tic. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo.. Dry. Yr.)
<br />February 23, 1922
<br />MOS.
<br />DAYS
<br />HOURS
<br />MBINS.
<br />7. SOCIAL. SECURITY mama
<br />507-12 -8870
<br />8e. PLACE OF DEATH
<br />MED& ❑ Immure =tall 'tuning HoiredLTC C7 Hospice Fenny
<br />❑ ERI t ❑Dsc.dent's Han.
<br />❑ ooa 0 040115 lr)
<br />air. FACEJTYJ 4**E IS not Inadtudon, gen street and numbed
<br />Tabitha Nursing Home
<br />Sc. CITY OR TOWN OF DEATH (M+ol d.Op Cods)
<br />Lincoln 68510
<br />ad. COUNTY OF DEATH
<br />Lancaster
<br />9e. RESIDENCE-STATE
<br />Nebraska
<br />914. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Id. STREET AND NUMBER
<br />118 North Cherokee Avenue
<br />9e. APT. N0.
<br />et OP CODE
<br />68803
<br />9g. INSIDE WY LINTS
<br />El va` 0 No
<br />10a MARITAL STATUS AT TIME OF DEATH ❑ Mauled ❑ Never
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Uniatown
<br />,Ob. NAME OF SPOUSE (FirsI. Middle, Last. Sutlx) I vile, glv• maiden name.
<br />Betty J Bartels
<br />11. FATHERII -NAME (Fate, Middle, LaL Bum:)
<br />Arend Frohling
<br />12. MDTNEWS-NAME (Flt. Middle, Emden Burn...)
<br />Alice Koch
<br />13. EVER IN U.S. ARMED FORCES? GM dates or service if Y...
<br />(Yes, No, orUldl.) Yes 11/19/1942 09/17/1945
<br />14a. INFORMANT-NAME
<br />P lis J Dreher
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />I8. METHOD OF DISPOSITION E" tt
<br />® ❑me.ew
<br />eR.w,.a..+ en'"" "
<br />Q IOY...yi
<br />CI Rsalaval OA.+
<br />ftie.'
<br />lab. L ! ('I
<br />Y
<br />tic. DATE Nee, Ory, TO
<br />June 5, 2015
<br />18d. CEMETERY, OR OTHER STATE
<br />CITY/TOWN
<br />Presbyterian Cemetery Campbell Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet CIty or Town. Bate)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />1714. Zip Cad.
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1e. PART L fort ale shinaLtands - Renee& 1*040* or awmFlKed.m- Rank none tinNeh. DORM rowwwedawds svdt *mmHg avost. APPROXIMATE INTERVAL
<br />rsr.iwla+Y onst, er.ererieulerfRril diem waaeet.hwM0a Or adala.r. 00 NOT AI IREVNTE EoYr enty ono erem en a We. M. atatioal Ins r n.0e.0Y.
<br />IMMEDIA TE CAUSE: ., onset to death
<br />IMMEDIATE CAUSE (nue
<br />rase
<br />r ase or condition mWtl�W at i, ,L J . �
<br />DUE TO, OR AS A OF: asst t ds
<br />Segtr.ntfagy Ilet conditions, r 14) ' ry ,` 11 -( "t�U' , ' 4l'• `
<br />any. Boding to ne came Natal No.,-,A- r'•'"" )
<br />ns
<br />on i a DUE TO, OR AS A .." ° j;+ ... OF r oS(et
<br />Enter to UNDERLYING CAUSE c) _� Q_Cer CxS2
<br />(disease or Injury that b I &saw d
<br />M.vsrda reertNh.p le aaeN+► to death
<br />t DUE TO, OR AS A OF:
<br />CAST [ 1 UA , C Vkc f �tL\ Chl-ttt WA/Al/12
<br />1 S. gIGMIFlCANr CONDf110! Hans le aeart but net ' h the ualedymq cam. given M PART!
<br />� d 1
<br />1L WAS MEDICAL examen
<br />OR W �GR1eI�TED ,
<br />WW1
<br />n No t pregnan
<br />Not pregnant within pant year
<br />(]Pregnant at time of death
<br />0 Not pregnant. It pregnant W Wn 42 ears or death
<br />❑Not pregnant, but pregnant 43 days to 1 year before deal
<br />❑Unknown It prevent within fhw pad year
<br />21 0
<br />❑ Aecldwtt [] Pending InvotWeatIon
<br />❑ Suicide ❑ Could not be determined
<br />2,e. F TRANSPORTATION INJURY
<br />❑ Passenger
<br />❑ P.drt4an
<br />❑ Other (Spaatty)
<br />21a Y0 � AUTOPSY PERFORMED?
<br />51(1",
<br />21d. WERE AUTOPSY PBIDBIGS AVAILABLE
<br />TO COMPLETE CA OF DEATH?
<br />❑ v*s
<br />224. DATE OF INJURY (M.... Day. Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY -At horns. fine, smut. tector7, office bulking. eonssuetlan era. etc. DIDenN)
<br />22d. INJURY AT WORK?
<br />❑'s ❑ No
<br />22*. DESCRIBE NOW INJURY OCCURRED
<br />224. LOCATION OF INJURY - STREET r NUMBER, APT. NO. croY1n:mu STATE OP CODE
<br />$
<br />h 234.
<br />5
<br />o
<br />230. DATE OF DEA ,IOW, Day, Yr.)
<br />S �t�j ac ,
<br />8 p g p1 i �
<br />Y p
<br /><i
<br />24 . DATE SINNED (Ma, Dry, Yr.)
<br />2414 TINS OF DEATH
<br />m
<br />DA j 6 Mo.. Day, Yr.)
<br />'P I l • • S
<br />23c. THE OF DEATH
<br />• m .
<br />24e. PRONOUNCED DEAD ( ., Day. ` *.)
<br />Md. TIME PRONOUNCED DEAD
<br />m
<br />2 3d To the . . of my dean occurred 1M Urns date and Puss ~ 2As On nu tondo a esatrnatiarl anewIMa*�lon, bt my opinion deaf occ rred
<br />and dm b cite d (11 "V A I r1 $ d the 85.. nte Mat place and dm to the 6MwMs) .fabd. (s s end TOO
<br />a
<br />L l _/�``TJ` r3 ffi
<br />28. DID CO USE CONTRIBUTE TO THE DEATH?
<br />ES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />21a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />1 ❑ YES
<br />}
<br />21b. WAS CONSENT GRANTED?
<br />Net Applicable I25. It No ❑ YES ❑ NO
<br />27.
<br />►.
<br />NAME, t AND •.,.. >._ OF CERTIFIER (Typo or Pion)
<br />• i t .' !.�e> _�i11 Nr�� ._.t . 011 ■ I. tilu411 tit 1 U
<br />28a r.. - BISNATURE ,( -
<br />•
<br />2814. DATE FLED BY *50*8TRAR (Ile., Day, rr.)
<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 VI7"A_ RECORDS.
<br />I •
<br />DATE OF ISSUANCE
<br />07/21/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201505748
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />e+ICD1Ie4v A7C At It ATIJ
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGIST IR
<br />DEPARTMENT OFJ1F(,EALTH Alm • s
<br />HUMAN SERVICES"
<br />5 , 2.4211.
<br />
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