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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 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 />A
<br />RUSSELL EOSLER
<br />DATE OF ISSUANCE
<br />202001587
<br />6/4/201 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 />LINCOLN, NEBRASKA
<br />1
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Theodor Augustin
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kenesaw, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />.508.40-2203
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health Lakeside
<br />lc. CITY OR TOWN OF DEATH (include Vic Coda)
<br />Omaha 88130
<br />9a. RESIDENCE4TAT
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />505 N Clark Ave
<br />9b, COUNTY
<br />Adams
<br />51. AGE - Last Birthday
<br />(`yrs,)
<br />92
<br />Sb UNDER 1 YEAR
<br />MOS. DAYS
<br />6a. PLACE OF DEATH
<br />HOSPITAL 0Inpatient
<br />ERIOutpat(ent
<br />I❑DOA
<br />ea. CITY OR TOWN
<br />Kenesaw
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 15, 2019
<br />6. DATE OF BIRTH (Mo., Day,
<br />April21, 1927
<br />OTHER 0 Nursing Home/LTC
<br />Cj Deoedent'e Home
<br />® Other (Specify)
<br />6d. COUNTY OF DEATH
<br />Douglas
<br />9e. APT. NO,
<br />9f. ZIP CODE
<br />88956
<br />Yr.)
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />II YES 0 NO
<br />101. MARITAL STATUS AT TIME OF DEATH [] Married 0 Never Married
<br />i
<br />11. FATHER'S -NAME (First, Middle, Lost, Suffix)
<br />George Augustin
<br />(� Married, but separated El Widowed 0 Divorced 0 Unknown
<br />1
<br />err
<br />P
<br />v
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yeo, No, or Unit.) NO
<br />18. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal ;❑ Other (Specify)
<br />lob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name
<br />Evelyn Mutts
<br />Give dates of senile' 0 Yes.
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Minna Kuehn
<br />14a. INFORMANT -NAME
<br />Bradley Augustin
<br />16a. EMBALMER -SIGNATURE
<br />Steve Brugh
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Concordia Cemetery
<br />17x. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 209 N. Smith Ave. PO Box G. Kenesaw. Nebraska
<br />16b LICENSE NO.
<br />1128
<br />CITY / TOWN
<br />Juniata
<br />CAUSE9F DEATH (See Instructions/11d examples)
<br />11.
<br />?ANTI. Enter tits Ngin of events- Aiming, injuries, or complications -that directly caused the death. 00 NOT enter tannino( events such as Girdles arrest,
<br />retipiratofy *mgt,or au7ar fibrillation without showing the etiology. DO NOT A89RSvtATE. Enter only ane cause on Y one. Add additional lines i1 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final S) Acute Respiratory Failure
<br />disease or condition resuking
<br />in death)
<br />Sequentially Ilat eeptetiont. if
<br />any. Wading to Me copse hated
<br />on line e.
<br />Enter the UNDERLYING CAUSE
<br />)dlaeam, er INury that Initiated
<br />the events re$Uging Ice death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />10 Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<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 />Hypertension
<br />20. IF FEMALE:
<br />0 00 Pregnant within peal year
<br />❑ Pregnant at Mme of death
<br />Ii Net pigment, but pregnant within 42 day. at death
<br />N41 pregwM,Dat pregnant 4i days to 1 year before death
<br />O 4Jt+itmow» a ansnant whMdtlo wet war
<br />21a. MANNER OF DEATH
<br />® Natural © 0.1.4(de
<br />0 Aecident 0 Pending Investigation
<br />0 Suicide 0 Dould not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Oriver/Operetor
<br />❑ Passenger
<br />0 Pedestrian
<br />Othor (Specify)
<br />14b. RELATIONSHIP TO DECEDENT
<br />son
<br />16o. DATE (Mo., Day, Yr.)
<br />May 20, 2019
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />88958
<br />APPROXIMATE -INTERVAL
<br />onset to death
<br />Immediate
<br />onset t0 dealt
<br />2 Years
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES Q NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />® YES lja NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />® YES ❑ N0
<br />221. DATE OF INJURY (Mo., Day, Yr.)
<br />222. INJURY AT WORK?
<br />OYER ONO
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />234. DATE OF DEATH (Mo., Day, Yr.)
<br />X May 15, 2015
<br />w° I
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />e 7.
<br />23c. TIME OF DEATH
<br />'LI
<br />dd. To the bat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(*) stated. (signature and 11(4)
<br />Adrian Dresesen, MD
<br />25. DIDTOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 N0 0 PROBABLY ® UNKNOWN
<br />4
<br />tt
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investlge ion, in my opinion dant (recurred at
<br />she time, date and place and due to the aua(e) stated. (Signature and MN)
<br />26a. HAS ORGANOR TISSUE DONATION BEEN; CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28. Is NO ❑ YES O No
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adrian Drammen, MD, 18901 Lakeside Hills Court, Omaha, Nebraska, 88130
<br />28a REGISTRAR'S SIGNATURE
<br />SCI. vs.� ,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 30, 2019
<br />
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