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STATE OF NEBRASKA
<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 />6/27/2016
<br />LINCOLN, NEBRASKA
<br />2 018019 5 6 DEPARTMENT HEALTH REGISTRAR
<br />AND AR
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Anthony William Rischling
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ord, Nebraska
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<br />iY
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<br />9d. STREET AND NUMBER
<br />1717W Division Street
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<br />7. SOCIAL SECURITY NUMBER
<br />508-19-7700
<br />8e. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />36
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />Married, but separated l ❑ Widowed ❑ Divorced ❑ Unknown
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<br />0
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<br />15. METHOD OF DISPOSITION
<br />® Burke) ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />Removal : ❑ Other (.Specify)
<br />11. FATHER'S -NAME ( First, Middle, Last, Suffix)
<br />Richard Anthony Rischlino
<br />E 13, EVER IN U.S., ARMED FORCES?
<br />8 (Y No, or link.) YES 'Dates
<br />Give dates of service if Yes.
<br />Unknown
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Smydra
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Mr. r(a June Whitsitt
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Gretchen Marie Todd
<br />14a. INFORMANT -NAME
<br />Marla June Rischlino
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18., PART L Enter the chain Of events- - diseases, injuries, or complications -that directly caused the death, Po NOT enter terminal events such as cardiac arrest,
<br />respiratOtY arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause on a fine, Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Central Nervous System Burkitts Lymphoma
<br />IMMEDIATE CAUSE '(Final
<br />:"
<br />disease or condition resulting
<br />APPROXIMATEINTERVAI.
<br />onset to tteaIRt'
<br />7 1/2 Months
<br />in death)
<br />Segde tially flat
<br />any, ;leading to t
<br />on hiie a,
<br />f itiorta
<br />use Usted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />difng in death)
<br />the events resu
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />20. IF; FEMALE.' ..
<br />0 110 goals within peat year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />•
<br />❑ Unkred lI it Iiregrianf within the past year
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<br />A
<br />3.�
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />c
<br />.0 122d. INJURY AT WORK?
<br />❑ YES :❑ NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />JUnre17,2016
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<br />4 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 20 2016 01:36 PM
<br />a:. O 3d. To the best of my knowledge, death occurred at the time, date and place
<br />$' o and due to the cause(s) stated. (Signature and Title)
<br />Adam Brosz, MD
<br />28a. REGISTRAR'S S IGNATURE
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />25: DID Tt EAGCO USE CONTRIBUTE TO THE DEATH?
<br />❑YES PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9e. APT. NO.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑yes j
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />9f. ZIP CODE
<br />68803
<br />16b. LICENSE NO.
<br />1454
<br />'2113, IF TRANSPORTATION INJURY
<br />Dever /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />© Other (Specify)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2016
<br />6. DATE OF BIRTH (Mo.., Day, Yr.)
<br />June 9, 1980
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />28b. DATE FILED BY REGISTRAR
<br />June 21, 2016
<br />9g. INSIDE CITY LIMIT
<br />El YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />June 22, 2016
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Sppci
<br />17b Zip -Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ No
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET IL NUMBER, APT.NO.
<br />ciry/TOWN
<br />STATE
<br />ZIP CODE i
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c PRONOUNCED DEAD (Mo., Day, Yr,
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED Dl
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title).
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES
<br />(M
<br />Day, Yr.).
<br />Coe
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