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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF,HEA(ATh A ' VI ;- IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA' LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR ,l1111tAL
<br />DATE OF ISSUANCE
<br />03/21/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA -
<br />202101879
<br />•OPER
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<br />202102053" .e NDdFTATHE
<br />1 I SERVICE4.
<br />DEPARTMENT OF HEALTH AND HUM
<br />C . RV CES
<br />CERTIFICATE OF DEATH
<br />13 01194
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Bu(flx)
<br />Donald Eugene Kaelin
<br />2. SEX ) 4,,I
<br />Male
<br />Yx DATirOEAT/I (Mo., Day, Yr.)
<br />i." Marlk5;'2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE - Last Bhthday
<br />5b. UNDER 1 YEAR
<br />_
<br />Sc. UNDO { I lAY
<br />6. DATEOF BIRTH (Mo, Day, Yr.)
<br />Ansley, Nebraska
<br />(YrL)
<br />80
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS."
<br />_
<br />June 12, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-6851
<br />8a. PLACE OF DEATH
<br />HOSPWAL 0 Inpatlent OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not hntlhRlon, give street and number)ER/Outpatlent
<br />Wedgewood Care Center
<br />00 Decedent's Home
<br />0 DOA 0 ober (SpecIfy)
<br />sc. CnY OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />8b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4020 Cannon Rd
<br />8e. APT. NO.
<br />8f. ZIP CODE
<br />68803
<br />8g. ASIDE CITY UMTS
<br />® YES 0 NO
<br />10e. MARITAL STATUS AT TIME OF DEATH EI Married 0 Never Married
<br />❑ Mewled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. 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 />Louts Kaelin
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Elma Williams
<br />13. EVER IN U.S. ARMED FORCES? OM dates of seance if Yes.
<br />(Ya, No, or Urlk.) No
<br />14a. INFORMANT-NA/0E
<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 />16b. LICENSE NO.
<br />1071
<br />18c. DATE (Mo., Day, Yr.)
<br />March 8, 2013
<br />❑ Cremation ❑Entombment
<br />D Removal 0 ober (Specify)
<br />18d. 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, Stab)
<br />All Faiths Funeral Horne, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />I
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />IL PART I. Enter the > WD of events --diseases, Injuries, or compuasone4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />fibrillation the DO NOT ABBREVIATE. Enter line. Add Ines if
<br />APPROXIMATE INTERVAL
<br />reeplretory arrest, or ventricular without showing etiology. only one cause on a additional necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />In d s.Ml
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, leading to the suss Wad
<br />Wm
<br />onset to death
<br />on a DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter tide UNDERLYING CAUSE c)
<br />Wean or Injury that Initiated
<br />onset to death
<br />Me events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART e. OTHER SIGNIFICANT CONDMONS+Condltlons contributing to the death but not resulting In the underlying cause given In PART I.
<br />CAD, Peripheral Vascular Disease, Atrial Fibrillation, Diabetes, Hypertension, Polycythe mia, Venous Stasis Changes
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />D Not pregnant within past year
<br />D Pregnant at ams of dant
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Invesngatlon
<br />21b. IF TRANSPORTATION INJURY
<br />D Driver/Operator
<br />0 Paaddgsr
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES ®No
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant but pregnant 43 Jaye to 1 year baron death
<br />o Unknown If pregnant within the poet year
<br />❑ Suicide❑ Could not a determined❑Outer
<br />0 Pedestrian
<br />(Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -Al home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specffy)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />t
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 5, 2013
<br />24e. DATE SIGNED (Mo, Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 18, 2013
<br />23c. TIME OF DEATH
<br />02:30 AM
<br /><'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. Yen PRONOUNCED DEAD
<br />. To the beet of my knowledge, WPM occurred at Me time, dive and pea
<br />due**, Title)
<br />!ee.On the basks of examination tinier Mvestlaatloe.In my opkdon eased oaarvd et
<br />Eand ausgq staled. (Signaling and
<br />Kimberly A. Mickels, MD
<br />E
<br />' Is
<br />tan see, date and phos and due lo the cativo) stout (8lgdulirs and Tete)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES NO r�-+I PROBABLY IIUNKNOWN
<br />26s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ®NO
<br />tab. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />27. NAME, TRL D ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE A- aV
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 19, 2013
<br />
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