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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA. DEPARTMEN71 9F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vf•TAtF,RBr qD$. •
<br />• s ,
<br />DATE OF ISSUANCE
<br />12/09/2013
<br />ASSISTANT-STATEREGISTRAR
<br />LINCOLN, NEBRASKA 2 0 210 4087 OEPARTMENT OF H&MA ;SERVICES EAL,TH AND
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEtVI$ES'
<br />CERTIFICATE OF DEATH
<br />13 05206
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS•NAME (First, • Middle, Last, Suffix)
<br />Dennis Marvin Hardekopf
<br />2. SEX ' '
<br />Malik:
<br />3. DATE OFDEATM (Mo., Day, Yr.)
<br />November 30, 2013
<br />4. CIT/ MD STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />5b. UNDER 1 YEAR
<br />5e. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo, Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs•)
<br />66
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 4, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />506-58-8348
<br />8a. PLACE OF DEATH
<br />ts4$iaAL 0 Inpatlent QIU B 0 Nursing Horne/LTC 0 Hospice Facility
<br />8b. FACILITY•NAME (If not Institution, give street and number)
<br />4078 W Hdwood Drive
<br />0 ER/Outpatient II Decedent's Homs
<br />0 DOA 0 Oar (Specify)
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand i*land 68803_
<br />r ..
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />ac. CITY OR TOWN
<br />Grand Island
<br />3d. STREET AND NUMBER
<br />4078 Wildwood Drive
<br />Be. APT. P40.
<br />W. ZIP CODE
<br />68803
<br />9g. INSIDE CIY UMTS
<br />0 YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF
<br />Dianna Lynn
<br />SPOUSE (First, Mlddie, Last, Sufic) H wife, give maiden name
<br />Wiles
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Earle George Hardekopf
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Roma Wilhelmina Hild
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 02/03/1966-02/02/1972
<br />14a. INFORMANT•NAME
<br />Dianna Lynn Hardekopf
<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 />16c. DATE (Mo., Day, Yr.)
<br />December 3, 2013
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Stats)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />1e. PART I. Enter thalami() of awnta-disasee, Injures, or complications -that directly caused Ea death. DO NOT anter terminal events such as cardiac arras.
<br />APPROXIMATE INTERVAL
<br />respiratory armet, or ventricular tlbriNatlon without showing the etiology. DO NOT ABBREVIATE. Ensu only Geta cause on a Nne. Add additional Ihres 11 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Prostate Cancer
<br />Meese° or condition resulting
<br />onset to death
<br />15 Years
<br />hi Mann) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions. If b)
<br />any. leading to the eau*. Noted
<br />III.
<br />onset to death
<br />on a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Ener the UNDERLYING CAUSE c)
<br />(disease or Inlury that InItlaed
<br />onset to death
<br />th events rurnlng In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />LAST d) i
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltkxa contributing to the death but not resulting in the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES r.r NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past yar
<br />Pregnant time Math
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 DAverlOparator
<br />Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />❑ at of
<br />0 Not pregnant, but pregnant within 42 days of Math❑
<br />❑ Not pr gnat, but pregnant 43 days to 1 year afore death
<br />❑ Unknown If pregnant within the past year
<br />❑ An:want 0 Pending Investigation
<br />❑ Suklda ❑ Could not W determlrretl
<br />0
<br />t•adapren
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<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 5ke, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 30, 2013
<br />S
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 4, 2013
<br />23e. TIME OF DEATH
<br />03:55 PM
<br />s g
<br />24e. PRONOUNCED DEAD (Mo, Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />. To tee beat of my knowledge. death oaunad at sew Oma, sae arw plea
<br />E and due to Me auee(s) stated. (Signature and Tide)
<br />Gary Settje, MD
<br />2
<br />~ a
<br />2M. On thee parse of eirarrdnation andlor hrvaggsUon, In my ephtlon daatlr oectared M
<br />tine me. Mae and place and Mus to pus sausels) atrde4. (Sklrrrnlnlure ant Tie)
<br />25. D10 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® N0 ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />ISSUE DONATION BEEN CONSIDERED?
<br />17 NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ■ YES ■ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Pri
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, : • 68803
<br />28a. REGISTRAR'S SIGNATURE Imo/ /^J 129.. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />(�� December 4, 2013
<br />
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