|
'BI 1
<br />�flf(
<br />i49A
<br />r^*\
<br />d114oA„ tP,1gi
<br />I6i
<br />\
<br />Nf,SSr✓ nr rirlJ7i) ld�
<br />1((t(�U
<br />,11eD;
<br />RI10
<br />/e ..1n,u,eer.err.� n aaa1
<br />d;94/eAiuleeeAl9
<br />11))111)0�1.
<br />1
<br />ee;.ru[h..aae,euuue,In,v ..m..�.a1
<br />.6""4°,01" ..""". d II f1/1 * t1\ ,.. ,00.!!l e1e11 �j
<br />_�..-.,.�. iv eel ylllld I , .ii1.
<br />r,/ l <_
<br />STATE OF NEBRASKA •
<br />ueb)�IrrrrsgWtll
<br />tie filltt
<br />rf irOffi1(IPQl
<br />ori
<br />VAVII
<br />'/111111�(i111at'
<br />�G11111111N .
<br />�;;I��i(((felrgim(1,111utltilit ilrf@4ia)}�1
<br />it
<br />h) aldtl. ,lll'0 eaPa,�, 41eEr,
<br />THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIESTHE DOCUMENT BELOW TO
<br />A TRUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />MAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />F ISSIIANC
<br />10/3)2022
<br />LINCOLN, NEBRASKA
<br />202207590
<br />r
<br />ut4cil > ,t:
<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 />DECEDENT`$ NAME Myth, Middle, Last, Suffix)
<br />HalOW Anthony :Roach
<br />4. CITY'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />CERTIFICATE OF HEATH
<br />rid Island Nebraska
<br />'f. SOCIAL; SECURITY' NUMSER
<br />505.34-8256 ..
<br />b. FACILITY.NAME (If not Institution, give street and number).
<br />Prairie W ids
<br />c�Tv QR'I"01AfN OF
<br />)DrIlt3hart :58632
<br />=SIDENCE.STA'
<br />casks <.
<br />d!$ ROET ml.! NUMi3El
<br />6108 +6ti :Street
<br />ITh (Include Zip Code)
<br />6a. AGE Last Birthday
<br />(Yrs )
<br />91
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE QF DEATH
<br />HOSPITAL. ❑ inpatient
<br />0 ER/Ou pada
<br />❑ pOH
<br />OTHER 0 Nursing Home/LTC Hotnpie Fp
<br />patient
<br />HOURS
<br />MINS.
<br />221.3319.
<br />3. DATE OF DE:tiTH (igto., pay Yr:).
<br />September 2q,:2022
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 24, 1931
<br />0 Decedent's Home
<br />® Other (Speclfy)ASSIS' Q LYING
<br />I8d. COUNTY OF DEATH \\''
<br />Hall
<br />Sb. COUNTY
<br />Hall
<br />ATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />tseparated 'Widowed 0 Divorced 0 Unknown
<br />1 1 ETHERS NAME (First Middle, last,' Suffix)
<br />Harold € 2oaoh
<br />3. EVER I i 1):54: ARMED FORCES? Gtve dates of service if Yes.
<br />(Yes No, or Unk.) Yes 01/20/1954-01/10/1957
<br />18. METHOD OFDISPOSITION
<br />O Burial ] panation
<br />E Cremation; cantektlbment
<br />❑ Removal ❑ Other (Specify)
<br />Sc. CITY OR TOWN
<br />Doniphan
<br />19b. NAME OF SPOUSE (First,
<br />Myrna M Aufdenkamp
<br />14a. INFORMANT -NAME
<br />Lisa Roberts
<br />Via. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />Middle, Last, Suffix) If wife, give mi
<br />12. MOTHER'S.NAME (First,
<br />Johanna A "Warnke.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />19a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town State)
<br />Apfel Funeral Home:; 1123 W. 2nd, Grand Island, Nebraska
<br />91#* iN81�IE. c1Ty tirrRITS
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or complications -that 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 one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Parkinson's disease
<br />in death),`...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially sat conditions,if b)
<br />ensfogolpg to t1+o 4etrea iiolod.
<br />lissasi orin)ury'�tite
<br />*events resulting
<br />14b. RELATIONSHIP TO 01e0EDENT
<br />Daughter
<br />16c. DATE (AMo , Day Yr.),,
<br />Septembelr 2') 2EI:;
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />onset‘ ':.'
<br />10 Y titi''
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8. PARTll OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but nl
<br />a'but'pregnant within 41 days of death
<br />Not pregnant, but pregnant 43 days to:1 year before death.
<br />nanownlf.p(egnadt 1tithln the past year
<br />OF 1N IURY(Mo , Day, Yr.)
<br />INJURY AT WORK?
<br />YES 0 NO
<br />21a. MANNER OF DEATH
<br />® Natural. ❑ Homicide
<br />0 Accident ❑ Pending Inuestlgaion
<br />I:.
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2111.1F TRANSPORTATION INJURY
<br />Driver/Operator
<br />❑ passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEL)TL"A.G'IIJt Mit.iER
<br />OR CORONR kEONTAC'1`il0
<br />❑ vas' ®NO
<br />ing:iit the underlying cause given In PART I.
<br />/
<br />21c. WAS AN AUTOPSY;P
<br />YES Nit
<br />21d. WERE AUTOPSY PU
<br />TO COMPLETE CALI
<br />0 YEE 0i;44
<br />22c. PLACE; OF INJURY'At heme,:farm, street, factory, office building, construction site, eto.y
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f L OCATION OP INJURY STREET & NUMBER, APT.NO.
<br />dv
<br />23a. DATE OF DEATII (Mo., Day, Yr.)
<br />September 26, 2022
<br />23b DATE SIGNED (Pao., Day, Yr.)
<br />SeriteMbe 26.2022
<br />a.
<br />EPO
<br />E
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />05:11 AM
<br />ad. Tethe best arti :knowledge, death occurred at the time, date and place
<br />ant*" to tint ceuse(s) stated. (Signature and Title)
<br />Richard Fruehlinc, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />P CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCEQ.DEAO'::;;,
<br />24e. Ori the basis of examination and/or Investigation, in my opinion death grad at
<br />.,? the terse, date
<br />and place and due to the cause(s) stated. (Signature elitt`fIBs) . .
<br />26a. HAS ORGANO. R imavecorwriom.sasN CONSIDERED?
<br />❑ YES EJ
<br />27=IVAMEr 11TE AND;#DRESS OF CERTIFIER (Type or Print •
<br />Richard FruehIing, MD, 3563 Prairieview St Ste 300, Grand Island, Nebraska 68803
<br />25. DK:MBA 3
<br />USE CONTRIBUTE TO THE DEATH?
<br />NQ M PROBABLY 0 UNKNOWN
<br />28b. WAS CONSENT GRANTED? :
<br />Not Applicable if 26a Is NO 0 YES
<br />Ic .
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 29, 2022
<br />
|