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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 <br />