|
',v11ROPY;
<br />t1l„ 41,11
<br />/WO
<br />Idol ,arra ..k41111111,11h11;nk,ud,
<br />sq3 1111,111
<br />iliPrl(,atdae..���lhi11,111,I,IPPi:., rn, °moii% r,i°.wNl.
<br />s.q
<br />11.
<br />405111111uN"'
<br />n445'/)1t111W,,,.._. ,Irl VIVP,
<br />v Oji alr°Mf ill
<br />HIINi)�
<br />111
<br />rlililllilil.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON RLE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS t,
<br />DATE DFISSUANCE RUSSELL FOSLER
<br />2 0 2 2 0 6 3 0 2 INTERIM ASSISTANT STATE REGISTRAR
<br />7/24/2018 DEPARTMENT OF HEALTH
<br />LINCOLN, NEBRASKA AND HUMAN SERVICES
<br />VICES
<br />STATE OF NEBRASKA - DEI ARTMENT O HEAt.TH AN► HUMAN SERVICES
<br />CERTPFICATE OE DEATH'
<br />O
<br />1. DECEDENTS -NAME (First Mf(
<br />Dean Francis' Engethau
<br />Crry AND S'IW
<br />ERRtT
<br />A11ian aNebraska...............
<br />.
<br />7. SOCIAL SECURITY NUMBER
<br />•
<br />507-.52-3527
<br />Sufnx)
<br />GN COUNTRY OF BIRTH
<br />5a ACsS.'L
<br />al
<br />77k.
<br />drlY
<br />moll YEAR
<br />.'.DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />Sb FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />ate_.
<br />2. SEX
<br />Male
<br />5c. ORDER 1 DAY
<br />HOURS MINS.
<br />1
<br />3. DATE OF DEATH (M0., Day, Vr.)
<br />July 121t'2018
<br />8. DATE OF el RYH (la
<br />June 22, 1941
<br />OTHER 0 Nursing Horne/LTC 0 Hospice Facility
<br />❑ Decedent's Home
<br />❑ Outer (Spedry)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803.
<br />a. RESIDENCE -STATE f. COUNTY
<br />Nebraska11 Hall
<br />9d. STREET ANDNUMBI
<br />2408 Cochin St.
<br />Oa. MARITAL STATUS AT; TIME OF DEATH ® Married E] Never Married
<br />❑ Berried but separated ❑ Widowed 0 Divorced '❑ Unknown
<br />l8d. COUNTY OF DEATH
<br />Hall
<br />CrfY OR TOWN
<br />Grand tstaiy
<br />Se. APT. NO.
<br />1.Ob. NAME OF.SPOUSE (Fbst,•. ,Middle, •
<br />Yvette..._ D&ttieison'..
<br />9f. ZIP CODE
<br />68801
<br />9g iNiSIDE CITY titen'S
<br />El YES ❑ No
<br />SS:
<br />18 PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Acute 4n Chronic Systolic CHF, Atrial Fibrillation, Hepatic Cirrhosis, Coronary Artery Disease:
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Richard Enpelhaupf
<br />MOTHER 'S•NAME (First, Middle,
<br />Velma Lee
<br />13. EVER::IN U.S.ARMED.:FORCES?
<br />(Yee Ntf of Unk) (,1,(S
<br />15 NtETHODOF'alsPC iTGDN
<br />❑`aural "❑ Donation
<br />ka Cremation ❑ Entombment
<br />❑:Romovel ©othar::(:sP y)
<br />Give dates of
<br />Ice if Yes.
<br />14a. INFORMANT -NAME;;
<br />Yvetba ..Enctethaubt
<br />f8a EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a Irt7NERA4N47a►E NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AliFaiths FuneratHome. 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATI•I .tSee urns
<br />18
<br />martEmyr;hit. iahain 1,{f (Optus- rliseeses, addles, or compliatlonshhat directly ceeeed the:' 00'4
<br />resplrato emu, ar vdntn#utar fibflNation without showing the etiology. DO NOT ABBREVIATE WIN oda
<br />IMMEDIATE, CAUBE:
<br />IMMEDutII CAUSE (Plain . ai Acute Kidney...lnjury
<br />dt.ease or condttion reautfing
<br />depths DUE TO, OR AS A CONSEQUENCE OF:
<br />:..........
<br />woo
<br />eo ie tnn.s 8epuentIath4mruselheI4fdany,:h ddeM '
<br />b) Sepsl
<br />on ma
<br />ru
<br />ion
<br />Etter the UNDERLYING CAUSE
<br />(disease: orituury that initiated;.
<br />the_°"ems ridtddle k+ death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Pneumonia
<br />b LICENSE NO.
<br />nd
<br />CITY f TOWN
<br />Gibbon
<br />xamoles)
<br />I to ethts such as cardiac street,
<br />a Nn.. Add additional. lineal, nee.
<br />14b. RELATIONSHIP::7O DECEDENT-'
<br />'Wife
<br />18c. TEM*, Day, Yr)
<br />July 16, 2018
<br />-STATE
<br />Ne 2.1tSka
<br />1711 ZIP Code .:..:'.
<br />68801
<br />APPROXWAT "INTER'tfAl.
<br />onset tette
<br />Days
<br />e
<br />bays
<br />onset to death
<br />Days
<br />onset tri Sh:
<br />0. IF FEMALE;
<br />❑ Not ptegnant tivithrn paaYyear
<br />© Pregnant at tone or team
<br />❑ Not pregnerik:lrit pregnant wl him a:
<br />flat pregtsta lut pregiiem 43 days tot
<br />tinknStsat i iattelneet , him tna tisk pear ;
<br />�
<br />22a. DATE OF INJURY ( 1o., Day, Yr.)
<br />:INJURY AT: 4'7
<br />YES Q NO
<br />ate. MANNER OF DEATH
<br />M Neturat 0 ftenhicide
<br />❑ Accident Q Pending Invest
<br />0 Suicide' ©CouljtiQt
<br />E OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2117 fF FRIaNSPORTATION.INJLIRY
<br />QDrteertOperater
<br />0 Passenger •
<br />Pedestrian
<br />p oNtsr:tapeCIfy)
<br />19: WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES NO:
<br />21c. WAS AN AUTOPSYI
<br />❑YES' 10NO
<br />MEP?:
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />To COMPLETE CAUSE OF. DEATH?:,
<br />0 YES .;' Q N(
<br />me, farm, street, factory, ice building, construction sloe, etc. (Specify)
<br />2Z LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />ia.
<br />. DATE (WREATH (Ma, Day, Yr.)
<br />CITY/TOWN
<br />STATE
<br />CODE
<br />25b. uATM SIGNED (Mo., Day, Yr,) 23c. TIME OF DEATH
<br />July 12, 2014 03:15 AM
<br />3d. To the best or my knowMdge, death occurred et the Ede. date aid place
<br />and due Ni the commis) staled. (Signature and Tale)
<br />V C. Anderson MCI
<br />25. DID TOBACCO UBE
<br />IB
<br />❑'YES 'EI NO ❑ PROBABLY . 27. NAME, TITLE AND ADOR€SS OF CERTIFIER (Type or Print
<br />Jay C, Anderson,:MD, 729 North Custer Avenue, Grand Is! and, Nebraska, 68803
<br />TH
<br />TH7
<br />KNOWN
<br />24e. On the halo or exarelasIon andfor krvaatigeton, N1, my epiien taste ecsuted a1
<br />the tMa, date end place and due to the eausa(5) stated. t$lpNure and Tate)
<br />2Sa:. HAS ORGAN OR TISSUE DONATN N BEEN CONappERE
<br />❑YES --:•:11 NG'
<br />26b.
<br />Not
<br />268
<br />N
<br />NATURE
<br />28b. DATE FILED W(
<br />July 18, 2018
<br />RA iY[ t ;Day, Yr.
<br />
|