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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 />DATE OF ISSUANCE
<br />............... ............
<br />....... ...... ...........
<br />2/24/2021
<br />LINCOLN, NEBRASKA
<br />E
<br />a,
<br />202101914
<br />•
<br />SARAH BOHNENKAMP
<br />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 />}. DECEDENTS:NAME (First, Middle, Last, Suffix)
<br />Kenneth Ro)f Lilienthal
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Laramie, Wyoming
<br />7. SOCIAL SECURITY NUMBER
<br />441-40-07889
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (Haat Institution, give street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OP DEATH (Include Zip Code)
<br />let
<br />Orand Islami 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />69
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />10 00024
<br />3. DATE OF DEATH (Ma, Day, Yr.);.
<br />January 6, 2010
<br />8. DATE OF BIRTH (Mo., Day, yr.1
<br />September 23, .1.940
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />❑ Hospice Faciltty
<br />Sd. STREET ANO NUMBER.
<br />503 East 19th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g, INSIDE CITY (EMITS+
<br />€YES:' ❑NO'
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<br />0
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<br />3
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<br />0
<br />Jr
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dorothy Jean Lilienthal
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ray Lilienthal
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Pauline May
<br />14a. INFORMANT -NAME
<br />Dorothy Jean Lilienthal
<br />14b. RELATIONSHIP TO DECEDENT;;'
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ;❑ Donation
<br />ISI Cremation ❑ Entombment
<br />❑ Remove( ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />16c. DATE (Mo., Day, Yr.)
<br />January 8, 2010
<br />STATED:
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PARTE. Enter the chain of events -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final -4 a) Dementia
<br />diatom. or COMOROS resulting
<br />in death! DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on line: a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAt/SE ' c)
<br />(diseeeSor injurythat initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in
<br />Chronic Obstructive Pulmonary Disease
<br />the underlying cause given in PART I.
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />5vears
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within peat year
<br />❑ Pregnant at time dams
<br />0 Not Oragnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />22a, DATE OF INJU RY (Mo, ; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑'Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES RI NO
<br />21d. WERE AUTOPSY FlNOINGS'AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, q
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />(Specify);
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 6, 2010
<br />CITY/TOWN:
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 7, 2010
<br />23e. TIME OF DEATH
<br />08:51 PM
<br />23d. TO the bent -Of my knowledge, death occurred at the time, date and place
<br />and doe to the cause(s) stated. (Signature and Title)
<br />David R. Colan, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YE8 IXC NO 0 PROBABLY 0 UNKNOWN
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<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death odcurred at:
<br />the time, data and place and due to the cause(s) stated. (Signature aiMTkle)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27. NAME, UTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO © YES 0 NO
<br />28a. REGISTRAR'S SIGNATURE
<br />JO- cacype"-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 8, 2010
<br />i
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