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WHEN HIS COPY trARRUES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY 'i7 E ORIGINAL RECORD ON FILE WITW THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVir, ES, WTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATB 0r= ISSt1ANCE _�
<br />2/2 .. 2022044 :. le
<br />.
<br />LINCOLNI'll, NEBR ' O SARAH BOHNENKAMP
<br />1. IASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />.. .;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />. ..
<br />C TI IC E OF DEATH 22 01184
<br />EN N/trM1i #First, Middle, Lasl, SufSx)1.
<br />1 fg1.111,
<br />2.8EX
<br />S. DATE OF DA7H (Mo, Day Yr.j `
<br />Qelbd t Cie Rathman
<br />Male
<br />`Janus 1 , 2 221.
<br />4. CITY AND ST . TE ,gR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ga. AGE • Lest Birthday
<br />b UNDER 1 YEAR
<br />gc. UNDER 1 DAY
<br />6. DATE OF SiR1H (Mo , Day, Yr j
<br />,,
<br />(Yrs)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Wood River Nf3br`ska'
<br />92:;:
<br />Febraa ';2Q 1929
<br />7 BiJt�tkL SE. .1. NUMBER
<br />81.a PLACE OF DEAV.Tk
<br />���$
<br />"
<br />HOSPITA� ❑ inpatisttt OTHER ❑Nursing home/LTC iltasttice Paoi1HY
<br />�$
<br />8b. FACILITY4AME (If trot institution, give street and number)
<br />❑ ERlOutpatient ® Decedetrt's Home
<br />. 13130 West Cedarview Road.11"
<br />❑ DDA ❑ Other (specify)
<br />8c DI1Y OR Tt1N1.NOFDEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />III
<br />Woad Rivet B�1.
<br />Hall
<br />9a R9SIDENCE4TATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />1.I1 .111 1111111,. 1
<br />11
<br />1.
<br />Nebraska'
<br />Hall
<br />Wood River
<br />11
<br />I'll. 119d
<br />BTIiEET AND NUMHEI? ... ;
<br />e, APT. NO.
<br />9f. ZIP CODE
<br />ED INSIDE CETY LIM4TS
<br />1313Q W t Cedaririew Road
<br />'
<br />"Middle,
<br />688$3
<br />Y4 NO
<br />10a:MAFdTA4 ETATiI § AT fiME OF DEATH ®AAarried ❑Never Married
<br />10b. NAME OF SPOUSE (ithst Leat Suffix) if wife, glue me�tten ntBlte
<br />g�
<br />❑ Married, but separatod ❑ Widowed ❑ Divorced ❑ Unknown
<br />Janice Sorensen
<br />11 SA,iHER S.. I.. . (First, Middle, Leal Stdfix) 12 MOTI . SAAME (First, Middle, Maiden Sumatpe)
<br />Herman H Rathman11 Mame M Seier
<br />D
<br />1S f;irE. IN U S ARMED FORCES? Give dates of service N Yes.
<br />14a. INFOftIiAAN7 NAME
<br />14b. RELATION IP TO
<br />(Yes, No. or unit.) Yes 04/10/1951-03/08/1953
<br />Janice Rathman
<br />Souse
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (AAs Day, Yr j
<br />Burial ❑ Donatton
<br />B
<br />❑Cremation ❑ En#otlrbmsnt
<br />Chris McCoy
<br />1191
<br />January 2�.. ,202
<br />0 Removal , ❑ Oster !spacDfy)1.
<br />18d. CEMETERY, CREMATORY OR Oii�THER LOCATION CITY /TOWN
<br />STATI
<br />8
<br />W®atlawn Memorial Park Cemetery Grand Island Nebraska
<br />11
<br />1.17a
<br />FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town■ Slats)1.
<br />1 rD EDP Cods
<br />Apfel FuOerai ltO ne, 1123 W. 2nd, Grand Island, Nebraska
<br />B8 i1;
<br />di
<br />+
<br />CAS OF I tr ction a ex m1.
<br />.. .
<br />18. PART I. Eller the chant � events. -0baasea, Injuries, or eompllcalorotftat directly ceased the death. DO NOT eller remtinel events such u areae mast, , APPROXIMATE INTERVAL"
<br />respiratory. arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary. ,
<br />IMMEDIATE CAUSE: i oras;"tOdgtlt}1
<br />IMfD1ATI1.
<br />cAt►isg I. a) adenocarcinoma of the lung 3 YeaCs
<br />!.
<br />dfs9daa4rdoAdiilRnra4#aNdg.
<br />"
<br />dea#lfi DUE TO, OR A8 A CONSEQUENCE OFc : onwt to death
<br />sequentially ilstd il'; ..b}
<br />'
<br />any,;leading to tare cases setas
<br />oa'rjjte a
<br />DUE TO, OR A8 A CONSEQUENCE OF: ; pnse#"#gt[oath
<br />EQrltlheulilft .""0t,`AUBL C)'
<br />-ty
<br />(diNateorinp ry:91stkiitiedad ..
<br />.
<br />the seT Ms resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 ori to death
<br />I
<br />d)
<br />��+i11
<br />1. 1.1-11,
<br />4s
<br />16 AART1.lI, OT#1ER SDGNII (CANT CONDITIONS Conditions contributing to the dsatit but not: resultingin the underlying cause given in PART
<br />t. 19. WAS Mf EJkANBIiER :'.
<br />ASCUi t, chronlC cambirled sy8#olio-diastgiic CHF, COPD, chronic resp:failure with hypoxia
<br />OR CORONEf#1;ON7ACTEDT'
<br />❑ YES NO
<br />":.{
<br />0 IF FEMALE
<br />21a. MANNER OF DEATH
<br />2111. IF TRANSPORTATION INJURY , 21c
<br />WAS AN AUTtiFBY PERFORMED? !:
<br />Nditr#agnaniwithfn hasY;ysar
<br />®Natural ©Homicide
<br />,❑ P1i+rorlOparator
<br />�,k".
<br />❑ Y tA#O
<br />11
<br />I"": 5)
<br />❑Pregnkntat tithe of deah,
<br />ri
<br />❑Aceltlerd ©Pending hwastlgatWn
<br />�ii ❑Pa9genger
<br />"
<br />rg
<br />U ptegrtasir„ but 00ithant wiedn 42 days of death
<br />❑suicide Could not be determined
<br />0: Pedestrian 21d.
<br />WERE AUTOPSY i#NIINfiB AkrA1
<br />❑ Not pregnant, but pregnant 42 days to 1 year before death
<br />[]
<br />� Other (specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />11
<br />:.
<br />:: ❑:;unknown.N.pregnatttlalthinthepastyear
<br />❑YES ©NO
<br />22a :DATE OF INJUi41r (Moi; Day, YrJ
<br />22b. TIME OF INJURY
<br />22c PLACE OF INJURYA. !tome, farm, street, factory, office building construction •RA; o1C ISpat?I€yj
<br />22d. "INJURY At WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑11 YES.::: ❑ N9'
<br />>
<br />.:1.
<br />;1 .
<br />22P IOCA1 ONsQP1NJrJR.Y•STREET&
<br />NUMBER,APT.NO. CITYrTOWN STATE Zt6 CpDE
<br />2Sa' I TE OF DEATH (Mo.,,Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b, TIME OF DEAfH
<br />.r Janua 19 2022
<br />a s
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATHJO
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />$
<br />3:13 PM
<br />'�1.
<br />B Tr):dte filet of roil knowletlga, dsatll occumd a the ams, date anti place
<br />a dvetstbe.causa(e) shretl. (8lgnehrro and Title)
<br />at
<br />RIe. tkt ate peels of ezamirretlon amvor Investigation, in my opinbn deaf# bcdurrf6
<br />the tlms, dots and and due to the causes) staretl. :
<br />~�<
<br />~g
<br />place (gignaurs antt'Mae)
<br />..
<br />E
<br />Steven Husen, MD
<br />ONTRIBUTE TO THE DEATH?
<br />2g. DIG TOBACCO USE C11
<br />26a. HAS QROAN,OR TISSUE DONATION
<br />BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />YES.11 X10 ".;❑ RROBABLY ❑UNKNOWN'
<br />YES NO
<br />Not Applicable If 28a is NO YES. ❑ NO >:.
<br />`" J :
<br />L
<br />', ype or Print)
<br />`
<br />Steven Htleen 2116 W Faidle #400, Box 9802, Grand Island, Nebraska, 68803
<br />11
<br />,MO,
<br />28a. REGISTRAR'S SIGNATURE � g
<br />Qw1
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.)
<br />t9
<br />January 31, 2022
<br /><.
<br />,
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