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1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Arthur Lange 2. SEX Male ; DATt r OF DEATH (Mo.,Day,Yr.) September 24, 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ord, Nebraska 5a. AGE -Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 22, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -24 -3919 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility El ERIOutpatient ❑ Decedent's Home ❑DOA ❑Other(Specffy) 8b. FACILITY -NAME (If not Institution, give street and number) Mary Lanning Memorial Hospital 8c. CITY OR TOWN OF DEATH (Include Zip Code) Hastings 68901 Bd. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY - . .. Hall Sc. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 202 E. 20th 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. V Harrison 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arthur Lange 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Clara Plejdrup 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 03/03/1944- 06/04/1946 14a. INFORMANT -NAME Virginia La e 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑Donation ID Cremation ❑Entombment ❑ Removal ❑otharIspedty) 18a. EMBALMER N TU' � a P N , � � , , 1 6b. LICENSE NO. C� / 67 16c. DATE (Mo., Day, Yr.) September 29, 2010 ` d. CEMETERY, CREMATORY OR 0 - ER LO aN CITY/TOWN STATE and Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) It PART I. Enter the phaln of events - diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest. or ventncular fibrillation without snowing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final 9/ a) / J� a V' (/' . APPROXIMATE INTERVAL onset to death y f7l h d 1 7 disease or condition resulting . C...0. J in death) lc DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) `/ -�'_ ". I ,r - ' (2 V , / J YIE �r any, leading to the cause listed / on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death v Enter the UNDERLYING CAUSE c) /_/ 1 S i. . o 1 r -S • (disease or injury that Initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES X NO 20. IF FEMALE: ❑ Not pregnant within past year ❑Pregnant at time of death ONot pregnant, but pregnant within 42 days of death • ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past year 21a. MANNER OF DEATH 'Natural ❑ Hornicide . ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES XNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 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 aW LL_ m li o WJ to u V .0 p 23a. DATE OF DEATH (Mo., Day, Yr.) -r� y-- /Q Z Y -0UZ 2 Y o E 0 o W z 9.; Z O =O U o 24a. DATE SIGNED (Mo., Day, Yr.) - 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) iv- 8_ /v 23c. TIME OF DEATH (9 . ' f m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To t best of my knowledge, death occurred at the time, date and pl and to the cause(s) stated: jfiignature and Ti`tlee)) 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 . r SACCO USE CONTRIBUTE TO THE D TH? DYES ❑ NO ❑ PROBABLY NKNOWN 26a. HAS ORGAN OR TISSUE .,, 90� ' NATION BEEN CONSIDERED? ❑ YES - �� t}-N0 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO \ 27. NAME, TITLE AND ADDRESS OF CERT IER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 1 Theresa Hatcher 715 N. Kansas, Hastings, NE. 68901 MD 28a. REGISTRAR'S SIGNATURE A. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) OCT 13 2010 N d 0. E 0 U N 1 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN0_H01AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIAL REE9kDS. = is . DATE OF ISSUANCE OCT 1 i 2010 LINCOLN, NEBRASKA STATE OF NEBRASKA 201506141 STiLNLEY gOOPER ACSSISTAA(T)STATE REGISTRAR DEA IR.TMENT OF HEALTH AND HUMAN : SER VICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES / OO • CERTIF OF DEATH 2 GT4