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x®2200438 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STA')1S[ICS CERTIFICATE OF DEATH 302445 1Ja. 16 FATHER - NAME FIRST William MIDDLE LAST Dibbern 17 Joy 7 MIDDLE Rathuan 18. WAS DECEASED EVER N U.S. ARMED FORCE$/ (Yes noor unci I IN yes gne Wer end dein d eennpsl No 190 INFORMANT 19a. INFORMANT • NAME Marvin Roth MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. DPI 11287 W. Capitol Ave. Wood River, NE 68883 20 EMBMM4ER - SIGNATURE 6 LICENSE NO. 40,7 NERAL HOME - NAME 957 Apfel Funerals Home 21a. METHOD OF DISPOSITION 210. DATE oBurial ❑ Removal ❑ Cnenledn ❑ Donor Dec. 31, 2001 21c CEMETERY OR CREMATORY NAME Mennonite Church Cemetery STATE 214 CEMETERY OR CREMATORY LOCATION CITY OR TOWN Wood River. NE 220 FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. 2x1 411 W. llth Street Wood River, Nebraska 68883 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR Tal. la. AND 149 Marvel bne1en ami and dear PART ' (al Septic Shock DUE TO. OR ASA CONSEOUENCE OF BN Chronic Myelogenous Leukemia Days Mwrval Oelmean Odle' end dears 2 Years C�I�:�r DUE TO. ORAS A CONSEOUENCE OF fel Interval etnmeen onset and dear OTHER SIGNFICANT CONDITIONS - CoAnno a ooraributing b M dean but not mimeo PART 261. ❑ ACc'Oe4N ❑ UndelenmMtl ❑Suicide ❑ Pending . ❑ Hamada eneaegasen 260. DATE OF INJURY /Att. Day. Yr/ 26c HOUR OF INJURY PART B F FEMALE. WAS THERE A 24 AUTOPSY PREGNANCY N THE PAST 3 MONTHS, � (Ages 10.54) Yea ❑ No O yes © j''I No I 29d DESCRIBE HOW INJURY OCCURRED M 25 WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER' Yes ❑ No El 19. INJURY AT WORK DK PLACE OF NJI -.N MLdm. Nrm. great Way Yea ❑ No ❑ • dleonB /sperarY/ 26g LOCATION STREET OR R.F.D. N0. CITY OR TOyN! STATE 27a DATE OF DEATH-Nas.--09r`Yq Deceii4trA,1 270 DATE /(tiro.. ase WM • • • 274 .To 29 OND TDSEEON ❑ YES 31. NAME ANCOADI S F, moor r Robe>`t` diek, M.D. 32a REGISTRAR �,� • • . I and duebam M 261 DATE SIGNED Hao. Dar Yr tab TIME Of DEATH PRONOUNCED DEAD !Ab Oxy. Yr.) 284. PRONOUNCED DEAD '*bon am On the been d eem'ron end or 149199non. et my opinion dears occurred at M entre. dela ehd place and due b die pawl$) Wad. 1509119. and TM(► ® NO 303 WAS CONSENT GRANTED, ❑ YES ❑ 110 Medical Center Omaha 68 - 32b DATE FILED BY REGISTRAR /Ab. Day Yrl JAN 24 2002 This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County Health Department, Oaaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions of this green certificate are not legal copies. Date issued: JAN222002 Registrar: 1 DECEDENT • NAME • • FIRST — MIDDLE LAST Heide Marie Roth 2 SEX Female 3. DATE OF DEATH Monet Dar Yarn December 26, 2001 4 CITY AND STATE OF BIRTH /y not n USA. norm county/ 51 AGE - Lan Birthday UNDER 1 YEAR UNDER 1 DAY 6 DATE OF BIRTH MMIP* Oar Yuri Hutchinson, Minnesota "al 42 S° MOS DAYS 5c HOURS '*N5 February 23, 1959 7 SOCIAL SECURTIY NUMBER 505-90-7684 6• PLACE OF DEATH HoeidITAL ti: moment OTHER ❑ Nursing Houle ❑ ER 0(Maben ❑ Resdence 1 FACILITY - Name /e not otAt414n gn► saws and numbell NHS/Clarkson ❑ DDA ❑ Omer $Qec'" 6e CITY TOWN OR LOCATION OF DEATH Omaha 16d INSIDE Yea CITY OMITS "A Nc ❑ 6e COUNTY OF DEATH Douglas 9a RESIDENCE - STATE Nebraska 9b COUNTY Hall 9c CITY. TOWN OR LOCATION Wood River 9d STREET AND NUMBER MdcludnpzD Coder 68883 1 9e INSIDE 11287 W. Capitol Ave. . Yee CITY X UMrc5 No ❑ 10 RACE - le g., While . Blacx American Indian "'Zile �j�� L ISoecdyl 11. ANCESTRY If wan. Mexican. German. etc' 11 German �!,� ❑� MARRIED ❑ WIDOWED NEVER ❑ DIVORCED MARRIED 13 NAME OF SPOUSE ill awe orve matron mire! Marvin Roth tea USUAL OCCUPATION 1Gne end door* dormung dmost 140 KIND OF BUSINESS INDUSTRY 15 EDUCATION (Speedy day l7 1s9 grade canteeledl or workingeven ear Health Care Elementary « l "I0.121 Cat . 'ted 5- 1Ja. 16 FATHER - NAME FIRST William MIDDLE LAST Dibbern 17 Joy 7 MIDDLE Rathuan 18. WAS DECEASED EVER N U.S. ARMED FORCE$/ (Yes noor unci I IN yes gne Wer end dein d eennpsl No 190 INFORMANT 19a. INFORMANT • NAME Marvin Roth MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. DPI 11287 W. Capitol Ave. Wood River, NE 68883 20 EMBMM4ER - SIGNATURE 6 LICENSE NO. 40,7 NERAL HOME - NAME 957 Apfel Funerals Home 21a. METHOD OF DISPOSITION 210. DATE oBurial ❑ Removal ❑ Cnenledn ❑ Donor Dec. 31, 2001 21c CEMETERY OR CREMATORY NAME Mennonite Church Cemetery STATE 214 CEMETERY OR CREMATORY LOCATION CITY OR TOWN Wood River. NE 220 FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. 2x1 411 W. llth Street Wood River, Nebraska 68883 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR Tal. la. AND 149 Marvel bne1en ami and dear PART ' (al Septic Shock DUE TO. OR ASA CONSEOUENCE OF BN Chronic Myelogenous Leukemia Days Mwrval Oelmean Odle' end dears 2 Years C�I�:�r DUE TO. ORAS A CONSEOUENCE OF fel Interval etnmeen onset and dear OTHER SIGNFICANT CONDITIONS - CoAnno a ooraributing b M dean but not mimeo PART 261. ❑ ACc'Oe4N ❑ UndelenmMtl ❑Suicide ❑ Pending . ❑ Hamada eneaegasen 260. DATE OF INJURY /Att. Day. Yr/ 26c HOUR OF INJURY PART B F FEMALE. WAS THERE A 24 AUTOPSY PREGNANCY N THE PAST 3 MONTHS, � (Ages 10.54) Yea ❑ No O yes © j''I No I 29d DESCRIBE HOW INJURY OCCURRED M 25 WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER' Yes ❑ No El 19. INJURY AT WORK DK PLACE OF NJI -.N MLdm. Nrm. great Way Yea ❑ No ❑ • dleonB /sperarY/ 26g LOCATION STREET OR R.F.D. N0. CITY OR TOyN! STATE 27a DATE OF DEATH-Nas.--09r`Yq Deceii4trA,1 270 DATE /(tiro.. ase WM • • • 274 .To 29 OND TDSEEON ❑ YES 31. NAME ANCOADI S F, moor r Robe>`t` diek, M.D. 32a REGISTRAR �,� • • . I and duebam M 261 DATE SIGNED Hao. Dar Yr tab TIME Of DEATH PRONOUNCED DEAD !Ab Oxy. Yr.) 284. PRONOUNCED DEAD '*bon am On the been d eem'ron end or 149199non. et my opinion dears occurred at M entre. dela ehd place and due b die pawl$) Wad. 1509119. and TM(► ® NO 303 WAS CONSENT GRANTED, ❑ YES ❑ 110 Medical Center Omaha 68 - 32b DATE FILED BY REGISTRAR /Ab. Day Yrl JAN 24 2002 This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County Health Department, Oaaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions of this green certificate are not legal copies. Date issued: JAN222002 Registrar: