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<br />WHEN MS . 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 4g
<br />DATE OF ISSUANCE
<br />7/18/2018
<br />LINCOLN, NEBRASKA
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<br />�•r 01906048 INTERIM ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND 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 />Delmar Dean Roth
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Chappell, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-48-6490
<br />5a, AGE - Last 811th
<br />(Yrs.)
<br />92
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />12102 West Capital Avenue
<br />day
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />El DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 4, 2018
<br />8. DATE OF BIRTH (Mo.,'bay,Yr.)
<br />September 7, 1925
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood. River 68883
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />12102 West Capital Avenue
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />sc. CITY OR TOWN
<br />Wood River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 WIdowed ❑ Divorced 0 Unknown
<br />lob. NAME OF SPOUSE, (First, Middle, Last, Suffix) If wife, give maiden name
<br />Evelyn Schweitzer
<br />O
<br />11. FATHER'S -NAME (First,
<br />Abe Roth
<br />Middle, Last, Suffix)
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Gascho
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Cindy Yoder
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />July 7, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Wood River Mennonite Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Wood River
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />It PART 1. Enter the chainotevents-.diseases, Injuries, or complications -that directly amass the death, DO NOT enterterailnpl events such as cardiac arrest,
<br />retpiratory arrest, or vemrieular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ons cause on a line.<Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Congestive Heart Failure
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition resulting
<br />in death)
<br />Sequentially (iet aortdhions, if
<br />any. Wading to the nesse listed
<br />on line
<br />Enter the UNDERLYING CAUSE
<br />(disease Or InithY 010t initlated:::
<br />ltinSIn death);;.
<br />the events rose
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<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 I.
<br />Chronic Kidney Failure,:
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />lint pregnant, but pregnant. 43 days to 1 year before death
<br />❑ Unknown if pregnant ',Alen the past year
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be detennined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Q Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSEOF DEATH?
<br />❑YES NO .
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />Des QNO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREETS NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 4, 2018
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 6.2018
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />10:45 AM
<br />tId. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the sause(s) stated. (Signature and Title)
<br />John A. Wagoner, MD
<br />25.0)0 TOBACCO USE CONTRIBUTETO THE DEATH?
<br />❑ YES ECINO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<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 />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 511 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />lea. REGISTRAR S S(GNAT(IRE
<br />28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr.)
<br />July 11,2018
<br />
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