I To Be CompletedNerlfled by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS-NAME (First, Middle, Last SOW -• • •. °
<br />Larry Dean Rhoads
<br />2. SEX
<br />Male
<br />6c, UNDER 1 DAY
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />January 16, 2016
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />April 3, 1941
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />York, Nebraska
<br />Se. AGE-Last Birthday
<br />(Yre.)
<br />74
<br />Six UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508-48 -0703
<br />Se. PLACE OF DEATH
<br />IIOSIIIAL N iopagard Q.ThE& ❑ Nursing HomMLTC ❑ Hospice Facility
<br />Sb. FACILITY-NAME (t not institution, give street and number)
<br />CHI Health St. Francis
<br />❑ ERlOutpatient ❑ Decedent's Home
<br />❑DOA ❑oth.r(SPetlr)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Cods)
<br />Grand Island 68803
<br />6d. COUNTY OF DEATH
<br />Hall
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />90. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1004 N. Sheridan Ave.
<br />9e. APT. NO.
<br />W. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Manned ❑ Newer Manned
<br />❑ Manned, but separated ❑ Widowed ❑ Divorced ❑ unknown
<br />1016. NAME OF SPOUSE (First Middle, Last, Suffix) R wife, give maiden name.
<br />Loretta Maya Kuehn
<br />11. FATHER'S-NAME (First Midge, Last, Suffix)
<br />Henry Rhoads
<br />12. MOTHER'S -NAME (FIM, Middle, Malden Surname)
<br />Maxine Schneider
<br />13. EVER IN U.S. ARMED FORCES? GIVE dates of service If Yes.
<br />(Yea, No, or Unk.) yes 12/01/59-
<br />141. INFORMANT•NAME
<br />Loretta Ma a Rhoads
<br />lab. RELATIONSHIP TO DECEDENT
<br />S a Ouse
<br />13. METHOD OF DISPOSmON
<br />ad Waal Liberation Liberation
<br />❑C,wrMdon ❑Entowp,wm
<br />❑Mnleyel ❑Ohhad6Mrily1
<br />16a. EM SIGNATURE /
<br />' 1 o �� ' iJ ,._i
<br />16b. UCENSE NO.
<br />/ 03 5 7
<br />130. DATE (Mo., Day, Yr.)
<br />January 20, 2016
<br />16S RY, CREMATORY OR 0 ER LOCATION CITY/TOWN STATE
<br />Wesdawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MMUNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />170. ZIP Code
<br />68801
<br />I To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See Instructions and examples)
<br />IL PART I. Enter Ms 1OMO.h theudy . dirty, karat, or oo,npiIaatio,a• flat dhet6y caned Or dead,. DO NOT enter taming! events man an sera to area. APPROXIMATE INTERVAL
<br />aaplaomy meat, or vmMreta ribMalon **nag showing Or etiology. DO NOT ARIREVIATE. Entror ally ene.arum on • Dm Add add1bm1 If noomary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final /j/,f� � /'� �tf/ J J �/
<br />deem* Or tondltlen mhdtng a) {/ � CH le Corr fa p t MI AA a rrt-if I�71 I . WI In ad 1.(t. s
<br />DUE TO, OR AS A CONSEQUENCE OF: omen* death
<br />j
<br />Segwmialy INA conditions, a /
<br />any, leading to tin cause Mated b) 0/ rlA 1 - e f,r a 5-) /�7iM J /S o d490
<br />on line e. DUE T0, OR AS A CON°S9QUENGE OF: onset to d
<br />Enter the UNDERLYING CAUSE 0 )
<br />Injury
<br />(dl.ase of that Initiated
<br />the Sva is moulting in Math) DUE TO, OR AS A CONSEQUENCE OF: onset to Math
<br />LAST
<br />d)
<br />16. PART E, OTHER SIGNIFICANT CQNDITIONS•Condltons conbibuIIng to the death but not resulting In the ande4ying cause glven In PART L
<br />Go ►1#a5 L...(. / / �� / or a -P SCa�
<br />a r 'lr�t
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEDT
<br />❑YES g NO
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />❑ Pregnant at Ems of death
<br />❑ Not pregnant, but pregnant warn 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknam If pregnant within is past year
<br />215. MANNER OF DEATH
<br />. .13(Naturel ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DdvrrOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Spxlfy)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES IR 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 />m
<br />22c. PLACE OF INJURY -At home, fans, stmt, factory, office building, construction MN. etc. (+Petty)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ No
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CrTYITOWN STATE MP CODE
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />3'w
<br />1 1
<br />h Y y
<br />E
<br />8
<br />.3 §
<br />V
<br />u
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />IM m
<br />g
<br />� �C ! ..: / __ ■
<br />23c. TIME OF DEA H
<br />/100 .1
<br />._ �/ .
<br />24c. PRONOUNCED DEAD (Mean, D5y Yr.)
<br />24d• THE PRONOUNCED DEAD
<br />m
<br />E 22Ct. To tin • . t of my , • • ge, death occurred at the 5me, date and place
<br />and • to the caws(*) Stated. (Signature and Titre)
<br />��.� 'toot-
<br />24e. On the bans of examination and/or Investigation, In my opinion death occurtud
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES J[NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />,r YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES ,Q NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />;Y1 k4, / g o M „Ave 6YZ"d 1stcot.d, me. 11T O3
<br />261. REGISTRAR'S SIGNATURE
<br />,fang A'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN S 6 2016
<br />DATE OF ISSUANCE
<br />01/29/2016
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA
<br />201600983
<br />r. 1.
<br />S1 AeILEY S. •COe'PER
<br />ASSISTNfj EGIS7
<br />D PARTI , 1, 4.THA 1X
<br />H.W 4N SERVICES °
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AdIQ JI MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D c fl.R MANY OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR -VIT, L¢ b
<br />16 20
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