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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO $E,A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE S ATB.�Ei9RTMENT OF HEALTH
<br />BUREAU.OF VITAL STATISTICS, WHICH IS TH 'GAL DEPOSITORY FOR
<br />VITAL RECORDS. ;_ -
<br />DATE OF ISSUANCE
<br />MAR 2 0 W9 5T 5Bt.S-*- cooPER-- DIRECTOR
<br />LINCOLN, NEBRASKA BUREAiI1~idt V�.TAL` STATISTICS
<br />200008194
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ,0 r '� �
<br />DECEDENT –NAME FIRS MIDDLE LAST SEX DA E OF DEATH (Mo., Day, Yr.)
<br />Albert Siebelt Rothfuss ,Male_ _
<br />_ ,
<br />.) S. DAYS HOURS . MINS.
<br />d S. American 60. 75 66. 6t:. 7
<br />7. S
<br />norm *Mr ) WIDOWED, DIVORC ED (Spstrdy)
<br />B. C
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind olwork done during meN K�1{D S
<br />S B
<br />,b. H
<br />Grand Island (Sp*riy ro. or No) give street and number) O.4- 04wt /Ew»r Rm . Iwpotient (Speriy)
<br />ab. , k. Yes i
<br />RESIDENCE–STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
<br />Yes iu.Nebraska 1
<br />)[CS N
<br />,. Herman Rothfuss 17. Sophia Goldenstein
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? ITffl1j �(�{j_�,/JAME– RELATIONSHIP– MAILING ADDRESS (STREET OR R.F.D. NO.. CITY oR TOWN, STATE, ZIP)
<br />M
<br />-„
<br />BURIAL, Cremation, Removal D
<br />DATE C
<br />CEMETERY OR CREMATORY –NAME L
<br />LOCATION CITY OR TOWN STATE
<br />urial N
<br />NEI.3 -11 -1989 2
<br />20,Grand Island City Cemetery Z
<br />Zoe Grand Island, Nebraska
<br />TURE 6 LICE SE NO. ^ �J� F
<br />FUNERAL HOME –NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />22Apfe1- Butler- Geddes 1123 W. 2nd Grand Island, NE. 688
<br />c
<br />DATE S1 NED (Mo. Day, Yr.) H
<br />=
<br />N
<br />t1ABANA T
<br />i.
<br />o
<br />o c{
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<br />„t 2
<br />24a. 2
<br />D
<br />l7
<br />HOUR OF DEATH g
<br />PRONOUNCED DEAD P
<br />PRONOUNCED DEAD(Hour) h
<br />h 8, 1989�g (
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<br />k : 2
<br />`W D
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<br />2Sd.(Signot.re end TiMe) •
<br />2!*. (Sigeot.v owd Ado). E
<br />---
<br />Richard F. DeMa , M.D., Nebraska Veterans Hare Grand Island Nebraska 68803
<br />l'J
<br />26a.(Sigeet.v)� • 1
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE USE ►ER LINE FOR I06). (b), ND (c)) Interval ►ween
<br />PART
<br />et ewsM and desM
<br />L� -_
<br />(n) Congestive Heart Failure 3 weeks
<br />DUE TO, OR AS A CONSEQUENCE OF. InNrvol between ewsot end deeM
<br />(b, Myocardial Infarction ; 3 weeks
<br />DUE TO, OR AS A CONSEQUENCE OF: + Intevel between _W end deeth
<br />(d
<br />PART OTHER SIGNIFICANT CONDITIONS – Conditiswt <enlrib.ting b death but nw related ►
<br />►ART 111. IF FEMALE, WAS THERE A A
<br />AUTOPSY W
<br />WAS CASE REFERRED TO MEDICAL
<br />Y.. 0 No ❑
<br />No 1
<br />(Sp -;F, V. M Me)
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., D
<br />DATE OF INJURY (Mw, Day, Yr.) H
<br />HOUR OF INJURY D
<br />DESCRIBE NOW INJURY OCCURRED
<br />300. 3
<br />30b. 3
<br />30c. M 7
<br />7(d.
<br />INJURY AT WOK PLACE OF I
<br />INJURY – At home, tone. strN1 ledery .
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO $E,A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE S ATB.�Ei9RTMENT OF HEALTH
<br />BUREAU.OF VITAL STATISTICS, WHICH IS TH 'GAL DEPOSITORY FOR
<br />VITAL RECORDS. ;_ -
<br />DATE OF ISSUANCE
<br />MAR 2 0 W9 5T 5Bt.S-*- cooPER-- DIRECTOR
<br />LINCOLN, NEBRASKA BUREAiI1~idt V�.TAL` STATISTICS
<br />200008194
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ,0 r '� �
<br />DECEDENT –NAME FIRS MIDDLE LAST SEX DA E OF DEATH (Mo., Day, Yr.)
<br />Albert Siebelt Rothfuss ,Male_ _
<br />_ ,
<br />.) S. DAYS HOURS . MINS.
<br />d S. American 60. 75 66. 6t:. 7
<br />7. S
<br />norm *Mr ) WIDOWED, DIVORC ED (Spstrdy)
<br />B. C
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind olwork done during meN K�1{D S
<br />S B
<br />,b. H
<br />Grand Island (Sp*riy ro. or No) give street and number) O.4- 04wt /Ew»r Rm . Iwpotient (Speriy)
<br />ab. , k. Yes i
<br />RESIDENCE–STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
<br />Yes iu.Nebraska 1
<br />)[CS N
<br />,. Herman Rothfuss 17. Sophia Goldenstein
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? ITffl1j �(�{j_�,/JAME– RELATIONSHIP– MAILING ADDRESS (STREET OR R.F.D. NO.. CITY oR TOWN, STATE, ZIP)
<br />,8. Yes, )
<br />BURIAL, Cremation, Removal D
<br />DATE C
<br />CEMETERY OR CREMATORY –NAME L
<br />LOCATION CITY OR TOWN STATE
<br />urial N
<br />NEI.3 -11 -1989 2
<br />20,Grand Island City Cemetery Z
<br />Zoe Grand Island, Nebraska
<br />TURE 6 LICE SE NO. ^ �J� F
<br />FUNERAL HOME –NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />22Apfe1- Butler- Geddes 1123 W. 2nd Grand Island, NE. 688
<br />ATH (Mo., ay, Yr.) D
<br />DATE S1 NED (Mo. Day, Yr.) H
<br />HOUR OF DEATH
<br />t1ABANA T
<br />i.
<br />„t 2
<br />24a. 2
<br />21b. M
<br />D (Mo., D ay, Yr.) H
<br />HOUR OF DEATH g
<br />PRONOUNCED DEAD P
<br />PRONOUNCED DEAD(Hour) h
<br />h 8, 1989�g (
<br />123c. o 3:10 P. k
<br />k : 2
<br />(Mo.,oar,Yr.)
<br />24d, _
<br />a,�ta O
<br />the ►ett e1 mY Lwewledge, death ea. d at the time, deto on �..d to the a
<br />_
<br />r111To t
<br />• ^'� '
<br />v 2
<br />2Sd.(Signot.re end TiMe) •
<br />2!*. (Sigeot.v owd Ado). E
<br />E AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIA OR COUNTY ATTORNEY) (Type or Prinl)
<br />Richard F. DeMa , M.D., Nebraska Veterans Hare Grand Island Nebraska 68803
<br />REGISTRAR DATE RECEIVED BY REgSj�R j J DIM
<br />26a.(Sigeet.v)� • 1
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE USE ►ER LINE FOR I06). (b), ND (c)) Interval ►ween
<br />PART
<br />et ewsM and desM
<br />L� -_
<br />(n) Congestive Heart Failure 3 weeks
<br />DUE TO, OR AS A CONSEQUENCE OF. InNrvol between ewsot end deeM
<br />(b, Myocardial Infarction ; 3 weeks
<br />DUE TO, OR AS A CONSEQUENCE OF: + Intevel between _W end deeth
<br />(d
<br />PART OTHER SIGNIFICANT CONDITIONS – Conditiswt <enlrib.ting b death but nw related ►
<br />►ART 111. IF FEMALE, WAS THERE A A
<br />AUTOPSY W
<br />WAS CASE REFERRED TO MEDICAL
<br />Y.. 0 No ❑
<br />No 1
<br />(Sp -;F, V. M Me)
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., D
<br />DATE OF INJURY (Mw, Day, Yr.) H
<br />HOUR OF INJURY D
<br />DESCRIBE NOW INJURY OCCURRED
<br />300. 3
<br />30b. 3
<br />30c. M 7
<br />7(d.
<br />INJURY AT WOK PLACE OF I
<br />INJURY – At home, tone. strN1 ledery .
<br />STRE R.F.D. W. CITY OB TOWN STATE
<br />/Specify ras er Ne) •like ►.ilding, eN. (Sp«iy)
<br />) 1
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