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IY w tY W U .o tl�l E 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Robert Eugene Engel 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniphan, Nebraska 7. SOCIAL SECURITY NUMBER 505-48 -9389 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 3108 Briarwood Blvd 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Emil B Engel Middle, Last, Suffix) I 12. MOTHEIR'S -NAME (First, Middle, Malden Surname) Nellie Brittan 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a/ Acute Myocardial Infarction With Arrhythmia disease or condition resulting APPROXIMATE INTERVAL onset to death Minutes DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Obstructive Pulmonary Disease onset to death Years in death) Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated DUE TO, OR AS A CONSEQUENCE OF: c) Hypertension onset to death Years the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) Hyperlipidemia onset to death Years 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. W FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not 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 22a. DATE OF INJURY (Mo., Day, Yr.) a 22d. INJURY AT WORK? N ❑YES ❑ NO 22b. TIME OF INJURY 5a. AGE - Last Birthday (Yrs.) 88 9b. COUNTY Hall Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION Cedarview Cemetery CITY / TOWN Doniphan STATE Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) W October 9, 2015 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH E z October 12, 2015 08:11 PM O 23d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) 2 Kenneth Vettel, MD 28a. REGISTRAR'S SIGNATURE jib Se :UNDER 1 DAY HOURS 'MINS. 5b. UNDER 1 YEAR MOS. DAYS 2. SEX, Mal 8a. PLACE OF DEA HOSPITAL ❑ I r TH patient ® EA/Outpatient ❑ DbA OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 10b. NAME OF SPOUSE (Furst, Middle, Last, Suffix) If wife, give maiden name 9e. APT. NO. 14a. INFORMANT -NAME Linda Borgreif 16a. EMBALMER - SIGNATURE 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 16b. LICENSE NO. 1328 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger d Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 3. DATE OVDEATH (Mo., Day, Yr.) October 9, 2015 6. DATE OF BIRTH (Mo., Day, Yr.) May 21, 1927 9f. ZIP CODE 68801 19g. INSIDE CITY LIMITS 1 1 ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) October 14, 2015 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IXI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 13, 2015 1 STATE OF NE ASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA D ARTMENT OF HEALTH..ANp,�'f SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FIL WITH THE NEBRASKA, QgP,OTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL CEPOSITORY FOR VTOL - R CRD ' ) l ..- ✓. i/ DATE OF ISSUANCE 10/16/2015 LINCOLN, NEBRASKA 201601844 .STANLEY S "CaOPER rASSIS N STATE REG(STR4/2 Q EA I NIt'g6TJdF o4L1H:4ilD :MOMAN SERVICES: • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICS; ; , ' ± i ..r ti CERTIFICATE OF DEATH