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<br />1N1 4fgf1ts 41.1131
<br />WHEN THIS '`COPY CARRIES THE RAISED SEALOF 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 RECORD 0 2110 5 8
<br />DATE OF ISSUANCE
<br />3/23/2020
<br />LINCOLN, NEBRASKA
<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 />1. DEGEDENTS•NAME (First, Middle, Last, Suffix)
<br />Edith Elaine Rodenbaugh
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Riverton, VVyominq
<br />a 7. SOCIAL SECURITY NURSER
<br />s db. ctC1LUTY-NAME (If not Institut)on, give street and number)
<br />E • IJNMC
<br />a,
<br />2
<br />v
<br />0
<br />U
<br />0
<br />FS
<br />Sc. CITY OR TOWN OF DEATH (include Zip Code)
<br />Omaha 68198
<br />!A RESIDENCE -STATE
<br />Nebraska
<br />Yd. STREET AND NUMBER
<br />1304 N. Cherry St.
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME {First, Middle, Last, Suffix)
<br />Wiliam Grable
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk.) No
<br />16. METHOD OF DISPOSITION
<br />® Surial 0 Donation
<br />❑ Cremation :Q Entombment
<br />0 Removal ❑ Other (speclfy)
<br />5a. AGE • Last Birthday M. UNDER 1 YEAR
<br />etre.)
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />Cf.YS
<br />70
<br />Tpa. Yt ;t•.A 1 ,r ,Y'Tii
<br />j tt;SPfT,'L Inpatient
<br />-II
<br />0 ER/Autpatler-t
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 03505
<br />3. DATE OF DEATH (MO., Day, Yr.) ,.
<br />March 10, 2020 '
<br />6. DATE OF BIRTH (Ido., Day, Yr.)
<br />July 14, 1949
<br />Hospide Facinty
<br />OTHER 0 Nursing Home/LTC
<br />D, '. ysr i Lr etre
<br />❑ Other (Specify)
<br />(
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />N. APT. NO.
<br />lob. NAME OF SPOUSE (First,' ' Middle, Last,
<br />William Dean Rodenbaugh
<br />"OTHERS -NAME (First,
<br />Cecil Dillingham
<br />14a. INFORMANT -NAME
<br />William Dean Rodenbaugh
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OROTHER LOCATION
<br />Grand Island City Cemetery
<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 />8f. ZIP CODE
<br />68801
<br />9g.INSIDE Ch1 Y CIINI7S
<br />I Yt s ❑ d/o
<br />Suffix) If wife, give maiden name
<br />Middle,
<br />18b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />Maiden Surname)
<br />8
<br />•
<br />CAUSE OF DEATH (See Instructions and examples)
<br />f• 14. PART I. Enter the chain of events- diseases, injuries, or compllcationsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />• respiratory arrest, or ventricular fibrillation without showing the si.eogy. DO NOT ABBf,4VIATE. Enter only one cause on a line. Add additional Iirr s If neceesr.y.
<br />3
<br />al
<br />m
<br />w
<br />O'
<br />m
<br />E
<br />IMMEDIATE CAI'EE.
<br />IMMEDIATE CAUSE Meet a) Cardiogenic Shoce.
<br />disarms or c etdIti(r!'•e3ultn
<br />in dead') DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If
<br />any, lending to the cause listed.
<br />b)Right Coronary Artery Dissection
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter** UNDERLYING CAUSE C)
<br />(diseaseorinjury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />8. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />Mitral Valve Vegetation, Embolic Stroke, Subarachnoid Hemorrhage
<br />20. IF FEMALE:
<br />® N fpregnantwfhrtpsttriar._
<br />ID1Pflhgn"ht A w"l of dealt
<br />0 Net pnrcnant, big pregnant within 42 days of death
<br />i0 Nur. pregnant, but pregnant 43 days tot year before death
<br />C 0 Unknown if pregnant wltdn the peat year
<br />2N.
<br />22.a. DATE OF INJURY (Mo., Day, Yr.) the
<br />ER
<br />v []YES ❑.NO
<br />d • 22f. LOCATION OF INJURY STREET
<br />• 22d. INJURY AT WORK? 22e. DESCDESCRIBE HOW INJURY OCCURRED
<br />& NUMBER, APT.NO. CITY/TOWN
<br />C .L4t Ain ret ...E.,,,. IMO., ua', 1:.)
<br />March 10, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Match 16.2020 08:46 PM
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />suiting in underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Dr vomPerator
<br />❑ Passenger
<br />❑ Pedeatnan
<br />❑ Other (Specify)
<br />INJUR
<br />14b. RELATIONSHIPTO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 16, 2020
<br />1713. Zip Coda
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />19. WAS MEDICAI..EXAMINER
<br />OR CORONER CONTACTED/
<br />❑ YES ®NO
<br />1c. WA2S AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, fann, street, factory, office building, construction site, et .(SpSClfy) ..
<br />a
<br />3d. To the best of my lulowledge, death occurred at the time, date and pan ���_
<br />Ind dna to dts causes) stated. (Signature and Title)
<br />2
<br />Joseph R Pawlowski, MD
<br />8
<br />g
<br />t1
<br />STATE
<br />r••u. Lig l L t b..C.J 01.1., ....%... r.,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />a c.ill:.:.... .i Vl,n
<br />ZIP WOE
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the 4aalr: of examination and/or Investigation, In my opinion death rice*** St
<br />the OM*, ilea and pace and due to the causes) stated. (Signature and Tat,)
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 1285. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO ®.PROBABLY ❑ UNKNOWN I ❑ YES j8J NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Joseph R Pawlowski, MD, 984455 Nebraska Medical Center, Omaha, Nebraska, 68198
<br />28a. REGISTRAR'S SIGNATURE
<br />�`_• rC-I.' T -o cam+ , ��• • .�•
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES fl N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 18, 2020
<br />
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