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a Admit 7' ABE w 0 J cc m n E 0 v 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) NO 15. METHOD OF DISPOSITION Burial 0 Donation Patricia R. Curran ❑ Cremation ❑ Entombment [}Removal ❑ Other (Specify) E 0 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 STANLEY . COOPER ASSISTA STATE REGISTRAR 3/5/2018 DEPARTMENT HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Harold W Korgel 4. C(TY @ AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH • Minot, North Dakota 7. SOCIAL SECURITY NUMBER 501-32-9166 b. FACILITY -NAME (If not Institution, give street and number) 1104 N. Hancock >Av. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 1104 N. Hancock Av 10a. MARITAL STATUS AT TIME OF DEATH ItSJ Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Korgel 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska CAUSE OF DEATHsSee instructions and examples) 8. 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, tdspiralory afeSt, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause: on a line. Add additional lines N necessary. IMMEDIATE CAUSE: a) Cardiac Arrest IMMEDIATE CAUSE (Final disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list Condlddne, N b) any, leading to the 'cause Listed on tine a. Enter the UNDERLYING CAUSE (disease or injury that 'rnitfaf#d the events resulting in death) LAST 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Cardiamyopathy, Atrial Fibrillation, Peripheral Vascular Disease 20. IF:FEMALE: a ❑ Not Pregnantvnthin past year U ❑ Pregnant at time of death ❑ Npl pregnent„but pregnant within 42 days of death Not pregnent,but pregrrant43 days to 1 year before death ❑ 1)gknown if prsgnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) cg .a 22d, NJURY AT WORK? ° [IVES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. a S Si U. . � z n W F U y o 3a. DATE •QF DEATH (Mo., Day, Yr.) b. DATE SIGNED (Mo., Day, Yr.) -J Z O 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25.Dip TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO ❑ PROBABLY ® UNKNOWN STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Grand Island City Cemetery DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) I 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Vivian B Edwardson 23c. TIME OF DEATH 201.80173g 5a. AGE - Last Birthday (Yrs.) 85 14a. INFORMANT -NAME Vivian B Korgel MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand island 5b. DER 1 YEAR 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide Cou)d' not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY /TOWN 26a. HAS ORGAN OR TISSUE bONATION BEEN CONSIDERED? ❑ YES J NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Sarah Carstensen, Chief Deputy Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE C DAYS 2. SEX Male 16b. LICENSE NO. 1092 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Margaret Hennes Grand Island 21b. IF TRANSPORTATION INJURY Driver /Operator 0 Passenger 0 Pedestrian Other lSPecify) 24a. DATE SIGNED (Mo., Day, Yr.) February 28, 2018 24c, PRONOUNCED DEAD (Mo., Day, Yr. February 17, 2018 3. DATE OF DEATH (Mo., Day, Yr.) February 17, 2018 8. DATE OF BIRTH (MO Da January 8, 1933 16c. DATE (Mo., bay, Yr.) February 23, 2018 STATE ZIP CODE 24b. TIME OF DEATH Approx. 02 :00 PM A w 3 08 0 o Sarah Carstensen, Chief Deputy Hall County Attorney 24d. TIME PRONOUNCED DEAD 02:45 PM 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) Yr) ❑ Hospice Facility 9g. INSIDE C(TYLIMIT ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse STATE Nebraska 17b, Zip Code l 68801 APPROXIMATE INTERVAL onset to death Immediate onset to death onset to death on 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ? Q NO 21c, WAS AN AUTOPSY PERFORMED ?: ❑ YES ® NO 21d. WERE AUTOPSY FINpI.NGS TO COMPLETE CAUSE OFDEATH7 ❑ YES ❑!NO 26b. WAS CONSENT GRANTED/ Not Applicable if 26a is NO ❑'YES NO 28b. DATE FILED BY REGISTRAR (MO„ Da y, Yr.) March 1, 2018 o death