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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 />n Ars ti t k iS S U NA 18
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S-NAME (First,
<br />Richard
<br />TY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />. SOCIAL SECURITY NUMBER
<br />508 - 28
<br />8b '.FACILITY -MIME (If not institulion, give street end number)
<br />St. Francis Medical Center
<br />8c.CITY OR: TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />90: RESIDENCE,BTATE
<br />Nebraska
<br />90. STREET AND NUMBER
<br />ga.: MARITAL STATUS AT TIME OF DEATH [Married O Never Married
<br />OIUarried,butsepaWad ❑ Widowed ()Divorced 0 Unknown
<br />1. FATHERSNAME (FIrs1, Middle, Lest.
<br />Everett Hale Good
<br />13„ EVER IN -S !ARMED FORCES? Give dales of service it yes, to a. INFORM/kW-RAISE
<br />tree ne. or dnk 1.1.5 Yes: 9123/1946 1 /5/1 48Virginia Good
<br />15. METHOD OF DISPOSITION
<br />?Sandal ❑ Donation
<br />Ci Cremation ❑Entombment
<br />h FiemOVal Other (Specify)
<br />Via. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, Clty or Town, Slate)
<br />Apfel Funeral Home 1123 West 2nd Street Grand Island, Nebraska
<br />8 PART ',Enter the shale of evenly - diseases. Injuries, or complications- That directly caused thedearh DO NOT enteriermirial events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing ma etiology. DO NOT ABBREVIATE.Enter only one cause on a line. Add additional fines II necessary.
<br />IMMEDIATE CAUSE;
<br />IM MEDIATE CAUSEIPIneI
<br />di,a e Ma Od5�ir/eesIRrrg
<br />(unto.)
<br />Sequentially list condition, d
<br />shy feed109Se lEw cause listed
<br />oelihe e
<br />BASS UNDERLTI6IG CAUSE
<br />(dieeaaa pr (nftttylhal Bleated
<br />R.1. Width M deMtt)
<br />Sr U
<br />PART II OTHER .SIGNIF n ICANT CONDITIONS•Condilfons contributing to the death bu(lWl repWling in . It* uundet(yng cause given in PART I.
<br />20. IF FEMALE:
<br />0::;NmpottoatItytilhin past year
<br />Piegnard el 1iSis Al death
<br />Id ol pregaan.1; but pregnant within 42 days of death
<br />O Not pregnant but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within Ike past year
<br />DATE OP INJURY. (Mo.. Day, Yr.)
<br />2diIPiJURYAT WORK
<br />C) YES QNO
<br />2, _" A ._......_.
<br />221; lOGATIt7e! OF INJURY
<br />nd .t
<br />23a. DATE OF DEATH (MO., Day Yr.1
<br />2 ts)
<br />201804414
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH fig 74149
<br />(b)
<br />Ic)
<br />(d)
<br />Middle.
<br />Hale
<br />STREETA NUMBER, APT. NO.
<br />9b. COUNTY
<br />Hall
<br />16a. EMBA
<br />ETERY. CREMATOR'/ cm OTHER LOCATI
<br />Mt, Vernon Cemetery
<br />CAUSE OF DEATH iSee insttNytio
<br />' ousel to death
<br />DUE TO, OR AS ACONSEOUENCE OF: '
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />21 a. MANNER OF DEATH
<br />U Natural UHomicide
<br />U Accidenrci Pending lnvesligar i
<br />U Suicide ❑ Cou18 not be dafermtned
<br />22b. TIME OF INJURY 22c. PLACE OF'.INJURY•At hOI
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23b. Day, Yr.) 23c.TIM O EATH
<br />..,._ name .� P aG t� �-
<br />ate beslat my knowledge, death octet ad et the tires. dale end place w;
<br />.: and:due 10 the causels) staled. (Signature and Tine y
<br />25. DID TOBACCO USE CONTRIBUTE TDHIEDEATH? ( 260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YEB N NO ❑ PROBABLY ❑ UNKNOWN Q YES .
<br />2? AfAME.TTTLEAND ADDRESS OF CERTIFIER PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type et Pnru)
<br />Richard' Fruehling M.D. 2116 W. Faidley •Grand Island
<br />28a. REGISTRARS SIGNATURE
<br />CRYPT
<br />La sl,
<br />Good
<br />Birthday
<br />So. AGE -L.
<br />(YIN.)
<br />78
<br />Suffix)
<br />50 UNDER I YEAR
<br />MOS. -: DAYS
<br />Ispalieni
<br />❑ ER/Outpatient
<br />O NA
<br />Sc : CITY DOOM
<br />Grand Island
<br />9e. APT: NO
<br />lob, NAME OF SPOUSE (First, Middle. Last, Ruh is) II
<br />Virginia Lee Pettit
<br />12. MOTHER'S'NAME (First,
<br />Virg
<br />16b. LI EJd N
<br />? V
<br />ns ais ex mmp)es)
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />Bu.COUNTY OF DEATH
<br />Hall
<br />CITY / TOWN
<br />Peru, Nebraska
<br />ail
<br />210.1 INJUR
<br />yDrteertOperaior
<br />OPa5EAAger
<br />U:Pedealrian
<br />❑ Omer (Specify)
<br />24e. DATE SWINED (Ma.. Day. Yr.)
<br />21c. PRONOUNCED DEAD (Mo., Day, Y,.)
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />MINS.
<br />MO ❑ Nursing Home /LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />O Other (Specify)
<br />91. ZIP CODE
<br />68801
<br />its, glAe maiden name.
<br />Middle. Maiden Surname)
<br />inia Marian Chandler
<br />?lc.
<br />STATE
<br />3. DATE OF DEATH (Mu., Day, Yr.)
<br />April.19, 2006
<br />S. DATE OF BIRTH (Mo., Day. Yr.
<br />November 17, 1927
<br />tab. RELATIONSHIP 10 DECE
<br />Wife
<br />16c. DATE (Mo -, Day. Yr. )
<br />April 22, 20 0 ,
<br />iota, atrea Taetoep ofice building. construction site, etc. ISpecify(
<br />26b. WAS CONSENT GRANTED?
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Q YES 3it'NO
<br />WAS AN AUTOPSY PERFORMED
<br />❑• YES .Y NO
<br />2.1d. WERE AUTOPSY FINDINGS N4MLABLE'T
<br />CCMI'LETE CAUSE OFDEATH?
<br />❑YES «110
<br />24b. TIME OF DEATH <:
<br />24d. TIME PRONOUNCEDDEAD
<br />Zoe. On tet hams 01,eeanimauon and/or lave ligation, in my opinion death occuded et
<br />the date: and place and due to the cause(s) staled. (Signature and Tele) 1K .
<br />NM Applicable it 28a Is N0 O YES ❑ N4 '
<br />68803
<br />17b. Zlp Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death
<br />9g. INSIDE CITY LIMITS
<br />YES b4,1°
<br />STATE
<br />STATE
<br />m
<br />I Bob. DATE FILED BY REGISTRAR (Mn., Day, Yr.)
<br />MAY - 3 2005
<br />ITT
<br />T(HS -ES 11/030
<br />)
<br />
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