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<br />WHEN' THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO Be A TRUE COPD 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 RECORDSt1,9
<br />'
<br />Q RUSSELL FOSLER
<br />9 O 2 O O O 9 2 ASANT STATE
<br />IST
<br />4
<br />Ao• OF HEALTH REGISTRAR
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />1/28/2020
<br />LINCOLN, NEBRASKA
<br />yl. DECEDENTS.NAME (First, MIddle, Last, Suffix)
<br />Alvin Elmer Rinke
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-3315
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />78
<br />$b. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Se. RESIDENCE•$TATE
<br />Nebraska
<br />9d. STREET AND NUMBER`
<br />4436 Calvin Drive
<br />9b. COUNTY
<br />Hall
<br />lab. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH(Mo., Day, Yr.)
<br />January 20, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr..)
<br />September 15, 1941
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />❑ Hospice Facility
<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 p 0 WIdowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First; Middle, Last, Suffix)
<br />Elmer Ernest Rinke
<br />lob. NAME OF SPOUSE (First, ;,Middle, Last, Suffix) If wife, give maiden name
<br />Sharon Kay Hetrick
<br />12. MOTHER'S -NAME (First, Middle,
<br />Leona Clara Goehring
<br />Malden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unk,) Yes 08/15/1966-12/31/1971
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />E Cremation ❑ Entombment
<br />0 Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Sharon Kay Rinke
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO. DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day,Yr.)
<br />January 22, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<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 />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1B. PARTL Enter the :Shain of eveiita--diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory *fleeter yentriq ilei flbrIllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cerebrovascular Accident
<br />disease or condition resulting
<br />in death) ......
<br />:;DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequpnbaliy(let coe atony, if i ;b)
<br />any,teedin90thecause0te4
<br />on line a _...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />.d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Dernen)ia
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant;t but pregnant within 42 days of death
<br />0 Not pregnent, kilt pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant when- the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION
<br />' ❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />a Other(Specify)
<br />INJURY
<br />APPROXIMATE INTERVAL •
<br />onset to death
<br />5 Days
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NQ
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />224. INJURY AT WORK?
<br />YES ❑ NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />2
<br />0
<br />23a. PATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 20, 2020
<br />23c. TIME OF DEATH
<br />04:22 AM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the caused') stated. (Signature and Title)
<br />Ryan 0; Ctoueh;, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<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 end due to the cause(s) stated. (Signature and Tills)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, 00, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'SSIGNATt.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Gay, Yr.)
<br />January 22, 2020
<br />
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