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<br />' '" STATE OF NEBRASKA
<br />pp
<br />ViiRMAYA
<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 />11/9/2016
<br />LINCOLN, NEBRASKA
<br />201608629
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Cop
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marvin Meese Henrichs
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ericson, Nebraska'
<br />7. SOCIAL SECURITY NUMBER
<br />505-44-3820
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />v • CI-11 Health St. Francis
<br />ix 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />o Grand Island 68803
<br />Sa. RESIDENCE -STATE
<br />t u Nebraska
<br />n 9d• STREET AND NUMBER
<br />>, 301 East Pine
<br />.0
<br />t
<br />100. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />3 11. FATHER'S -NAME (first, Middle, Last, Suffix)
<br />d
<br />John Henrichs
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />8 (Yes, No, or Unk) Yes 03/27/1957- 10/01/1957
<br />m
<br />F
<br />1 5. METHOD OF DISPOSITION
<br />® Burial d Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Ksmo eel ❑ Other (Specify)
<br />ii 20. IF FEMALE;
<br />❑ Not pregnant within past year
<br />V ❑ Pregnant at time of death
<br />❑ Not pregnant,, but pregnant within 42 days of death
<br />• ❑ Not pregnant,but pregnantds days to 1 year before death
<br />D'''°' if pragnatd within the past year
<br />g 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d.:INJURY AT`WORK?
<br />•
<br />❑ YES Q NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF MEATH (Mo., Day, Yr.)
<br />October 19
<br />23 b. DATE SIGNED (Mo., Day, Yr.)
<br />October 25, 2016
<br />22b. TIME OF INJURY
<br />0 9d. To the best of my knowledge, death occurred at the time, date and place
<br />$ G and due to the cause(s) stated. (Signature and Title)
<br />•Travi$ S. Hageman, MD
<br />25. Ut0 TOBACCO US E CO. NTRIBUTE TO THE DEATH?
<br />Q YES 0 NO ❑ PROBABLY ❑ UNKNOWN
<br />9b. COUNTY
<br />Hall
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />© ER/Outpatient
<br />❑ DOA
<br />16a. EMBALMER-SIGNATURE
<br />Gwen K. Hyronemus
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Janice Benke
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />01:32 PM
<br />CITY /TOWN
<br />Sc. CITY OR TOWN
<br />Alda
<br />1 28a.REGISTRAR'S SIGNATURE 5
<br />5b. UNDER 1 YEAR
<br />9e. APT. NO.
<br />f 12. MOTHER'S -NAME (First,
<br />Ella Meese
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 0 N
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />j 24a. DATE SIGNED (Mo., Day, Yr.)
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />CAUSE OF DEATHJSee instruct 9ns.and examples)
<br />4$. PART 1. Enter the eham of events- -diseases, injuries, or complications -that directly caused the death, DO NOT enterterminal events such as cardiac arrest,
<br />rdaprratory arrest, a ventdcuta, • fibrillation without showing the etiology. CO NOT A££tt,ZVIATE . ;,"e eaucc on a fine: Add addition( lines a nace=.eary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />in death) _.
<br />21G IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 other (Specify)
<br />9f. ZIP CODE
<br />68810
<br />Middle, Maiden Surname)
<br />14a. INFORMANT -NAME
<br />Janice Henrichs
<br />6b LICENSE NO.
<br />1448
<br />� 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Pneumonia
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 19, 2016
<br />6. DATE OF BIRTH (Mo.,<; Day, Yr.)
<br />June 3. 1939
<br />24b. TIME OF DEATH
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred
<br />the time, date and place and due to the cause(s) stated. (Signature and. Title)
<br />28b. DATE FILED BY REGISTRAR (Mo., Da
<br />November 1, 2016
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo„ Day, Yr.)
<br />October 24, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />1713 Zip Code
<br />68803
<br />APPROXIMATE INTERVAL::
<br />Years
<br />Sequentially fiat bonditions; if
<br />any, isadingto the cause tlstad
<br />on lines
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease Of injury }fiat initiated:
<br />onset to death
<br />the events tesuit(pg: m death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 0 61
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ea NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STATE ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
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