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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/14/2021
<br />LINCOLN, NEBRASKA
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<br />202202384
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<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. DECEDENMNAME (First, Middle, Last, Suffix)
<br />Yolanda Kay Rathman
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505452-3686
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lelerid.68203
<br />9a. RESIDENCE -STATE
<br />Nebraska,
<br />9d.;STREET AND NUMBER.
<br />911 E Delaware
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />10a. MARITALSTATUS' AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 14477
<br />3. DATE OF DEATN.(Mo., Day, Yf)
<br />October 22, 2021:.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 28, 1939
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />❑ Hospice FaG(lity•
<br />99IN$IDE CITY LIMIT$
<br />Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Tom Walter Rathman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) j 12. MOTHER'S -NAME (First,
<br />Lola Hartman
<br />Hans kinsman ''
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yea, No, or Unk.) No
<br />1S. METHOD OF DISPOSITION
<br />Burial ©Donation
<br />LJf Cremation ❑Entombment
<br />0 Removal ' ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Tom Walter Rathman
<br />16a. EMBALMER -SIGNATURE
<br />Trent Wagner
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />16b. LICENSE NO.
<br />1257
<br />Middle, Malden Surname)
<br />CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />October 29, 2021
<br />STATE
<br />Nebraska
<br />:17a,.FUNERA.LHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Solt -Wagner Funeral Home, 1507 17th Street, Central City, Nebraska
<br />17b. Zip Code
<br />68826
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) malnutrition/failure to thrive
<br />IMMEDIATE CAUSE (Final
<br />Manisa or condition resulting;'
<br />Sequentially list conditions, if
<br />any,: leading to tilecauae:Neted
<br />on!hod a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease'or Injury.that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resuitingfin the underlying cause given in PART I.
<br />transverse Myelitis , asthma
<br />20. IF FEMALE::.
<br />❑ Not pregnant within pastyear
<br />© Prarpremat:ifineof dead :''
<br />❑ `Not pregnaitt, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑; Unknownif:pregnent within the pest year
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Hodicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b; IF TRANSPORTATION INJURY
<br />❑ Drover/Operator
<br />'❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onsetto death
<br />1 Year
<br />onset to death
<br />Chronic
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER' CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO .,
<br />225. DATE OFI.NJURY (Mo ; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES❑ NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. {Spa
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t LOCATION OF INJURY STREET a NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 22, 2021
<br />CITYJTOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 27, 2021
<br />23c. TIME OF DEATH
<br />11:35 PM
<br />23d. TO the tract of my knowledge, death occurred at the time, date and place
<br />and duetothe Cause(s) stated. (Signature and Title)
<br />Ryan D Crouch,
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ®NO ❑ PROBABLY 0 UNKNOWN
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />'ZIPCODEEM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />244/.On the basis of examination and/or investigation, in my opinion de9Moifurr d et
<br />• the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES_
<br />❑ NO
<br />2?. NAME TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Crouch, , Nebraska,
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />October 27, 2021
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