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1 A tI *oh � �9 * ! STATE OF NEBRASKA x a ura dal \ULM' /Y a B K u b b utu,aa r.: babtfa 0 W LL a, m a E c a I- i WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/22/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald Melvin Frederiksen £ITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup Ferrv:Township, Nebraska 7. SOCIAL SECURITY NUMBER 508-30-4369 8b FACILITY -NAME (If not Institution, give street and number) Park Place- A Golden Living Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2208 West 15th Street Enter the UNDERLYING CAUSE (disease or injury that initiated the events raeuimtg:in death) LAST.: 0. IF F EMALE: 0 Not pregnantwithin past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death Not pregnan pat pregnant days to 1 year before death • tlpkndwn if pregnalit withif the past year 23a. DATE OF DEATH (Mo., Day, Yr.) November 16, 2016 28a, REGISTRAR'S SIG STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) Yes 07/21/ 948- 04/23/1952 5. METHOD OF DISPOSITION ® Burial ❑ Donation Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Gwen K. Hvronemus DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22d. INJURY AT WORK? DYES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. • 23b. OAT EE SIOIEC («o,, Dzy, Y• 123 x. TIME OF DEATH I t z November 17, 2016 1 07:04 PM 0 < 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 g and due to the cause(s) stated. (Signature and Title) Z ! Richard Freehling; MD CITY /TOWN 201707319 5a AGE Last Birthday (YrS.) 86 14a. INFORMANT-NAME Phyllis Frederiksen 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES J NO ❑ PROBABLY ❑ UNKNOWN ❑ YES LI NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehlin9, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 DAYS STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Male HOURS I 16b. LICENSE NO. 1448 8d. COUNTY OF DEATH Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN 5c. UNDER 1 DAY Westlawn Memorial Park Crematory Grand Island 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERED? MINS. OTHER ® Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 CAUSE OF DEATH See instructions and exam r Ies 13. PART i. Enter the chain of events- - diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal 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) Complication Of Alzheimers Dementia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list coedttidns, if b). any leading to the cause _.. _.. on line a. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pedestrian 0 Other (Specify) STATE 4c. PRONOUNCED DEAD (Mo., Day, Yr. axe 3. DATE OF DEATH (Mo., Day, Yr.) November 16, 2016 6. DATE OF BIRTH (Mo. Day, Yr. April24, 1930' 10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ❑ Mauled, but separated;:; ❑ Widowed ❑ Divorced ❑ Unknown Phyllis Dubbs 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Guy Frederiksen Mabel Heinemenn on 24b. TIME OF DEATH 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ID YES 19 09376 ❑ Hospice Facility 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) November 23, 2016 STATE Nebraska 17b. Zip' Co 68803 APPROXIMATE :INTERVAL onset to death 2 Months onset to death onset *death: 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES' Ea NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP COD 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 28b. DATE FILED BY REGISTRAR Mo., Day, Yr.) November 18, 2016