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M 1 G1 N fNS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALT&4W4UM SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE O THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL Cam`, THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE , DEC 2 2 1998 = svrsnn LINCOLN, NEBRASKA HEAL D HUMAN SERM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND F; - c11NA vrrAL STAns77c§ - CERTIFICATE OF T)F/k-T#T 200007681 SERVICES FILE WITH :WHICH IS SUPPORT 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Monts Day Yearl Rodney A. Bell, Sr. Male December 10, 1998 1. CITY AND STATE OF BIRTH td not it U.S.A.. name country) Sa. AGE - Last BirtlWay I UNDER 1 YEAR UNDER / DAY 6. DATE OF BIRTH tMorift Day Yearl Giltner, Nebraska IYrs.l 57 1 5b. MGS, I DAYS Sc. HOURS' MINs. j February 14, 1941 7. SOCIAL SECURTIY NUMBER Sa. PLACE OF DEATH 507 -54 -2510 HOSPITAL: ❑ ..1, ant OTHER: Nursing Home - - -- 1 ❑ ER Outpatient ❑ Residence fib. FACILITY - Name /d not instpNnon. give sheet and number/ r St. Francis Skilled Care ❑ DOA ❑ Other /spur", Iq fie. CITY. TOWN OR LOCATION OF DEATH _ 6d. INSIDE CITY LIMITS fie. COUNTY OF DEATH Grand Island, Nebraska Yes ® No ❑ Hall 9a. RESIDENCE - STATE 91b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (MCkrdkg Zrp Code) 9e. INSIDE CITY LIMITS Nebraska Hall Alda 1 8175 S. 60th Road 68810 Yes ❑ No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le.g.. Italian. Mexican, Garman. etc) i0 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE td wl/e. give maiden name/ at) (Spscm White (Specify) German /American NEVER DIVORCED Judith K. Riess 14a. USUALOCCUPATION /Givekitdo/workdone during mast�� lab. lip, d KIND OF BUSINESS INDUSTRY O 15. EDUCATION (Specify only hose! pads com~) Els Mnt+nl2$eCOfaary 10 -t21 coup It -Ia5•I Of rocking even rekredl Contractor /Car enter Construction 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME F. Donald E. Bell Irma R. Mohlman 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (YSg„t1o. s unk.) IN yea. give war and dates d services) II 08 -31 -59 to 05 -13 -60 Judith Bell 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 8175 S. 60th Road, Alda, NE 68810 20. EMS E - SK NAT E 8 L EHSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. _ CEMETERY OR CREMATORY NAME q ❑ Burial El F mo.al December 14, 1 98 Giltner Cemetery 22a. FU RAL HO E60AME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑Cremation 11 Donation Giltner, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO., CITY OR TOWN. STATE. ZIP) 601 N. Webb Road, Grand Island, NE 68803 -4050 21 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)) I Interval be~ onset and death PART Respiratory arrest 18 months (at DUE TO, OR AS A CONSEOUENCE OF I Interval between tlruet and death Metastatic small cell carcinoma of the lung (b) I _ _ DUE T ;. OR: S A CONSEQUENCE OF' I Interval between txlset and death I I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART tll IF FEMALE. WAS THERE A AUTOPSY WAS CASE REFERRED TO MEDICAL PREGNANCY II COPD IN THE PAST 3 MONTHS? EXAMINER OR CORONER? Fly" (Ages 10 -54) Yes No No yes No X 26a. 26b. DATE OF INJURY /MO.. Day. Yr.) 2fic. HOUR OF INJURY 26d. DESCRIBE NOW INJURY OCCURRED Accident � Undetermined M ❑ Suicide [] PeMirg 260. INJURY AT WORK LlAq EE �ppp qqtt 26t_ oRCe bdMirIN INJURY /Spec�ilyl farm. street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation yes ❑ No ❑ 27a. DATE OF DEATH /Mo.. Day Yr/ 28a. DATE SIGNED tMo. Day. Yil 28b. TIME OF DEATH as 12 -10 -98 asp M g 27b. DATE SIGNED (MO.. Day. YO c. TIME OF DEATH 28c. PRONOUNCED DEAD lido.. Day. Yrl 211d. PRONOUNCED DEAD (Hduri 12 -15 -98 12:15 P M €� M x gw 2 a 0 To the best of my kno sy(,dEtur at Me time, date a; ace and due to the tested. / 269. On the basis of examination and,or nvesugabon, in my opnion death occurred al causelsl v the time. date arts place and due rote cause(s) stated. I na and T tle �4) S nature and Title 29. DID TOBAC USE CONTRIBUT H 30.a HAS ORGAN OR TISSUE DONATION BEEN - ONSIDERED? 30.b WAS CONSENT GRANTED? YES 1:1 NO ❑ UNKNOWN E] YES Y NO ❑ YES NO nW Vrt.Cnrrncn 1- T- inn, UUNUNLH J YHTbitilAN UH UVUN I Y A I I UHNtYI (1Y(ta Qr rrmr) r� • • le f