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STATE OF NEBRASKA
<br />sew
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA4T0,704 _
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA OLVARtajohf
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fg R Altig.ikEF
<br />DATE OF ISSUANCE
<br />03/21/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND,HUM
<br />CERTIFICATE OF DEATH
<br />202101879
<br />VI, ;"y, IT CERTIFIES
<br />ALTH AND
<br />'rJI jL E� • ` OPER
<br />SSJ i`T, ATE REG.
<br />a x NrdF HEA,
<br />gr$ERVICE:
<br />4 .,%:'
<br />z`13 01194
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Donald Eugene Kaelin
<br />2. SEX 't L
<br />Male y'�yM
<br />DATE g'SEATft jMo., Day, Yr,)
<br />35;'.2013:
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />Sb. UNDER 1 YEAR
<br />Sc. UI R{.DAY
<br />8. DATE'OFBIRTH (Mo., Day, Yr.)
<br />Ansley, Nebraska
<br />(Yrs•)
<br />80
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS°
<br />June 12, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-6851
<br />8a. PLACE OF DEATH
<br />H20IA1. 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />Ob. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />ad. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4020 Cannon Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10*. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF
<br />Dolores Ann
<br />SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Ely
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Louis Kaelin
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elma Williams
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Dolores Ann Kaelin
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />166. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />March 8, 2013
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 />To be completed by: CERTIFIER
<br />it PART I. Enter the f4alp of events - diseases, Injuries, or complIcatlons4 at directly caused the death. DO NOT enter Nnninal events such as cardiac meet,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT AaaREVIATE. Enter only one cause on a line. Md additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAM (Final a) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially bat conditions, if b)
<br />any, leading to the cause listed
<br />fine
<br />onset to death
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c).
<br />(disease or injury that Initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18, PART N. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />CAD, Peripheral Vascular Disease, Atrial Fibrillation, Diabetes, Hypertension, Polycythemia, Venous Stasis Changes
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20. IF FEMALE:
<br />o Not pregnant within past year
<br />Pregnant timeof at death❑YES
<br />ElQ
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Accident ❑Pending investigation
<br />21b. IF TRANSPORTATION INJU
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />®NO
<br />❑ Not pregnant, but pregnant within 42 days of deathQ
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown I pregnant within the past year
<br />EISuicide❑could nes M determined❑Other
<br />vedeeMan
<br />(Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILAB -
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify!
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET a NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 5, 2013
<br />a
<br />24a. PATE SIGNED (Mo, Day, Yr.)
<br />-
<br />24b. TIME OF DEATH
<br />ii,.
<br />23b. DATE SIGNED (Mo., Day, Yr.)23x.
<br />March 18, 2013
<br />TIME OF DEATH
<br />02:30 AM
<br />'
<br />24x. PRONOUNCED DEAD (Mo, Day. Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0
<br />Eand
<br />~
<br />2atl. To tin best of my knowledge, death occurred at tie tine, date and place
<br />due b tin cause(a) stated. (Signature aid TEN)
<br />Kimberly A. Mickels, MD
<br />B
<br />2N. On the Mats of examination antlror Irnves igatiori, In my opinion dash spurred
<br />the time, data and place and due to the ause(s) staled. (Signature and TEN)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES P NO 40� PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES P NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Island Nebraska, 68803
<br />Grand
<br />28a. REGISTRAR'S SIGNATURE/ jej allot/sot,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,IYr.)
<br />March 19, 2013
<br />
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