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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE ;A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/17/2016
<br />LINCOLN, NEBRASKA
<br />death)
<br />2 01604918
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />CAUSE OF DEATHJSee instructions and examples)
<br />PARt t. Enter the chain of events diseases, injuries, or complications -that directly caused the death.DO NOT enter terminal events such as cardiac arrest,
<br />fespiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Arrest
<br />3,seaon - vY GooO,,IO,I iaaui ia,y
<br />Coto
<br />STANLEY S. DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />A P P ROXf M A TE:I N TERVA L :
<br />onset to death
<br />Hours
<br />a
<br />0
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Richard Mathew Lempke
<br />4: CITY STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Na
<br />braska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -72 -9951
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />• CHI Health €St. Francis
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1408 Huston Avenue
<br />9b. COUNTY
<br />Hall
<br />Ifla. MARITAL STATUS AT, TIME OF DEATH ❑ Married ® Never Married
<br />Q Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13.: EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NQ
<br />15. METHOD OF :DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />[ [{ Other': (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />61
<br />MOS.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Norman T Lempke
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alice F Tuma
<br />14a. INFORMANT-NAME
<br />Iola Torres
<br />16a. EMBALMER-SIGNATURE
<br />Tracey Dietz
<br />5b. U
<br />NDER 1 YEAR
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 10, 2016
<br />September 25, 1 "954
<br />6. DATE OF BIRTH (Mo., Day, Yr.)',;
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9C. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS' •
<br />® YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />16b. LICENSE NO.
<br />1328
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Elmwood Cemetery
<br />CITY / TOWN
<br />St. Paul
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />14b. RELATIONSHIP TO DECEDENT
<br />Cousin
<br />16c. DATE (Mo., Day, Yr.)
<br />April 20, 2016
<br />17b.2lp.Code
<br />68801
<br />20.IF:FEMALE: ;1
<br />❑ Not pregnantwRhin past year
<br />U ❑ Pregnant at time of death
<br />.; ❑ Nut pregnant;:put pregnant within. 42 days of death
<br />❑ Not pregnant( bet pregnant43 days to 1 year before death
<br />❑ Onknown it pregn4el:Willtinthe past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />O
<br />F
<br />Sequentially list Conditions, if
<br />any, leading 10 the cause I($ext
<br />on line a •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Squamous Cell Carcinoma Of Left Tonsil
<br />onset to death
<br />4 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />Enter the UNDERLYING CAUSE
<br />(disease or lhlurythat iniiated,.
<br />the erenri fesuk)ii in fleeth)
<br />LAST:'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset fo death'
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Paroxysmal Atrial Fibrillation, Coronary Artery Disease, COPD, Colon Polyps With ; Dysplasia, Prurigo Nodularis,
<br />Depression /Anxiety
<br />22d.4NJURY ATWORK?
<br />❑ YES O NO
<br />22b. TIME OF INJURY
<br />25. " DID TOBACQ0 USE CONTRIBUTE TO THE DEATH?
<br />YES NO' ❑ PROBABLY ❑ UNKNOWN
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />236. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH
<br />May 12, 2016 11:55 PM
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 10, 2016
<br />23(1, To the best of my knowledge, death occurred at the time, date and place
<br />and due to the eause(s) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other(Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BE
<br />❑ YES I l NO
<br />EN CONSIDERED?
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />[] YES Et NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET &NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />•
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO. 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Kimtaerly A Mickels, MD, 729 North Custer Avenue, Grand. Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE ` / / ` pt#
<br />28b. DATE FILED BY REGISTRAR (Mo„ bay Yr.)
<br />May 13, 2016
<br />
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