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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NS ASTE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO ARVR,`COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE ARTMENT OF.` ALtH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LE G.AL.-bEPOSITORY F6k.
<br />VITAL RECORDS.
<br />hr '.
<br />DATE OF ISSUANCE
<br />APR 2 3 1991 STANLEY 1 0 R )AR�ECTOR
<br />�.
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS
<br />200107323
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH 1: r-
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Morin, Day, Year)
<br />Louis NMN Rathman
<br />Male
<br />Aril 7 1991
<br />4. CITY AND STATE OF BIRTH (d not m U.S.A., name counoy)
<br />Sa. AGE -Last &nhday
<br />IVrs.l Sb.
<br />/
<br />6. DATE OF BIRTH (Monts, Day, Year)
<br />MOS. DAYS
<br />-"OURS MINE.
<br />Alda, Nebraska
<br />82
<br />March 22, 1909
<br />7. SOCIAL SECURITY NUMBER
<br />v
<br />8a. PLACE OF DEATH HOSPITAL -. E&patienl C ER Outpatient C DOA
<br />505 -48 -5006
<br />I OTHER C Nursing Home C Residence :: Other (Specityi
<br />Bb. FACILITY - Name (d not institution, give street and number)
<br />tic. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />(Specify Yes or Noll
<br />Be . COUNTY OF DEATH
<br />'St. Francis Medical Center
<br />Grand Island
<br />Yes
<br />Hall
<br />i 9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />90. STREET AND NUMBER (including Zip Code/
<br />% INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1310 S. Lincoln 68801
<br />Yes
<br />10. RACE - le.� White, Black. American Indian,
<br />11. ANCESTRY le.g.,halian, Mexican. German, etc.)
<br />12. MARRIED.NEVER MARRIED.
<br />13. NAME OF SPOUSE („ wife, give maiden name/
<br />etc.) (Sp(.9,)
<br />White
<br />( Specdy)
<br />American Ob
<br />WIDOWED, DIVORCED (Specify)
<br />Married
<br />Vivian E. Ellison
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />of working his, even of reoredl
<br />KIND OF BUSINESS INDUSTRY
<br />Elementary or Secondary 10.12) 1 College 11 -4 or S -I
<br />114b.
<br />Maintenance I_k�
<br />Bakery 610
<br />8th Grade
<br />16. FATHER - NAME FIRST MIDDLE LAST MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />117.
<br />George NMN Rathman Dora NMN Wiese
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES? ' 9. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP0t 8000 01
<br />(Yes, no, or unk.) 18 yes, give war and dates of services)
<br />Ni - - - - -- Vivian Rathman 1310 S. Lincoln Grand Island Ne.
<br />20a. BURIAL, Cremation Removal,
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />Aril 10, 1991
<br />Westlawn Memorial Park
<br />Grand Island Nebraska
<br />21. EM LMER - S NATURE LICENSE NO.
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 688 01
<br />�,25 '1G
<br />Livin ston- Sondermann 505 W. Koenig, Grand Island Ne.
<br />23. IMMEDIATE CAU E (ENTER ONLY ONE CAUSE PER LINE FOR (a(. (b), AND (c)) Interval between onset and death
<br />PART
<br />Axw y al 's
<br />la) r A
<br />Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF I
<br />I
<br />1
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART EGNANCV NALE, PAST 3 MONTHS?
<br />24 (Specify Yes or No)
<br />2S EXAMINER OR CORONER? MEDICAL
<br />PART
<br />II
<br />-
<br />(Specify Yes or No/ 1 6
<br />/�
<br />Yes ❑ No O
<br />i (�
<br />le
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />26b. DATE OF INJURY (MO.,Day, Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATK)N (Specify)
<br />26e. INJURY AT WORK 26f.
<br />PLACE OF INJURY - At home, farm, street, factory,
<br />269. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />(Specify Yes or No)
<br />office building, eta /Specify)
<br />27a. DATE OF DEATH (Mo., Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day, Yr.)
<br />28b. TIME OF DEATH
<br />k April 7, 1991
<br />=�
<br />d
<br />a5
<br />27b. DATE SIGNED (Mo.. Day, Yrl
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo., Day, Yr)
<br />28d PRONOUNCED DEAD /Hour/
<br />N April 9,
<br />9:31 a.
<br />nip
<br />8
<br />E"��
<br />� Q �
<br />b
<br />27d. To the best of my know) ea titiimme, date and place and due to the
<br />ause(sl stated.
<br />n:!:
<br />28e. On the basis of examination ands investigation, In my opinion death occurred at
<br />the nme. date and place and due to the cause(s) stated.
<br />.,
<br />Si nature and Tids
<br />Si nature and Tale
<br />29a. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />ORGAN OR TIS UE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTEO?
<br />❑ YES ❑ NO UNKNOWN
<br />�31aS
<br />O YES NB
<br />O YES C NO
<br />31. NAME AND ADDRE55 Ur L&HnrtcH Irrrt oo. �.vnvn�.. .+• • ••- ._.... _.. ___....
<br />a D. R. Cronk M.D. - 908 North Howard - Suite 105 - Grand Island NE 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day, Yr)
<br />...� Aalaml_ I APR 2 3 1991
<br />
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