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<br />STATE OF NEBRASKA
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<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 FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSJTORY,FOR VITAL RECORDS
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<br />RUSSELL FOSLER " DEPARTMENT HEALTH AND
<br />INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES
<br />STATE OF NEBRASKA •:DEPARTMENT CIF" HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Richard Daniel Raffle
<br />2. SEX
<br />Male
<br />1
<br />8 0811
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 21,2018
<br />4. CI'E'Y'AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Norfolk, Hebra:
<br />7. SOCIAL SECURITY NUMBER
<br />50696-9221
<br />$a. AEE:- LastiIit'gtd$y Bb. UNDER 1 YEAR
<br />.(Yr94i.
<br />55 .
<br />Sb FACiLi'Y4NAME (If nat;:Institution, give street and number)
<br />Cart Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />90.RESIgENGE STA'
<br />Nebraska i`
<br />9d. STREET AND NUMBER
<br />4234 Norseman Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL S ATUSAT TIME OF DEATH l] Married 0 Never Married
<br />Marbled, blit separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />David Raile
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ISI EIJOutpauent
<br />9c. CITY 013. TOWN
<br />Grand Island
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />e. DATE OF BIRTH (Mo., DSS,
<br />October 24, .1
<br />OTHER 0 Nursing HomeiLTC
<br />o Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />2
<br />pica Facility
<br />99. INSIDE CMT1f,LIMITS
<br />';'
<br />al YES D NO
<br />10b, NAME OF SPOUSE (First,:.. Middle, Last, Suffix) if wife, give maiden mime
<br />Denise Marie Greenweit
<br />12. MOTHR'S-NAME (First, Middle, Maiden Surname)
<br />Elaine Ruppert
<br />13. EVER IN (./ S.ARMED'FORCES? Give dates of service if Yes.
<br />(Yes No or link.)- No
<br />15: METHOD OFDISPOSITION
<br />®.BUNdI ❑Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Qther (Specify)
<br />14a. INFORMANT -NAME
<br />Denise Marie Raffle'
<br />184 EMBALMER -SIGNATURE
<br />Steve Brugh
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park CenieterV
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Horne, 1123 W. 2nd. Grand Island. Nebraska
<br />18b. LICENSE NO.
<br />1126
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSH(P:.TODECEDENT
<br />18c. DATE (M«. Day YK j
<br />June 27, 2018
<br />CAUSE OF DEATH ISee instructions and examples)
<br />16. PART 1 Enter. the chain at events- -diseases, Injuries, or compikations•thatdirectly caused the: death DO NOT enter ten»#nal events such as cardiac arrest,.
<br />respiratory arrest. orventnicular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cause ;on aline. Add additional lines If necessary.:
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Myocardial Infarction.
<br />disease or condition resulting
<br />In deo" DUE TOOR AS A CONSEQUENCE OF:
<br />sequendaay lbt conddims it b , )Coronary.Artery Disease
<br />any, leading tb the taiise fisted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that Initiated
<br />ti teirenK resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST... d)
<br />STATE
<br />Nebraska
<br />ITbilia Code
<br />68801.
<br />APPRQkiMATE POW
<br />onsetto:denti
<br />20 Minutes
<br />onset:to demi
<br />10
<br />YeartW
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Hygeri pidem a
<br />20.1F:FEMALE;
<br />❑ Not pregnantwdtdapastyear
<br />D,mPregnantat time of death
<br />Q Akot pregnann.bat pragnentwithin 42 days of death
<br />D slot pfegnailt* but pregnalm 09 days to 1 year before death
<br />Q Unknown it pregnant wdhin the peat year
<br />21a. MANNER OF DEATH
<br />® Natural D Hannicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ could not tie determined
<br />21E.IETRANSPORTATION INJURY
<br />0Yhtwr/Operator
<br />0 Passenger
<br />aPedestrian
<br />1 .1 Other(Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />J4Q
<br />21e. WAS AN AUTOPSY.I.'enn:1RMED.
<br />❑YES ®NO
<br />21d. WERE AUTOPSY AVMABLE
<br />TO COMPLETE CAUSE QF DEATH?
<br />D YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />_22d. INJURY AT:WO7
<br />DYES ONO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET NUMBER, APT.NO.
<br />*I
<br />Sc,
<br />I 2
<br />23a f1KTE OF DEATH (Mo., Day, Yr.)
<br />June 21,.:18
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />08:20 AM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 26,:2018
<br />29d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Tide)
<br />-!:Gary Settje, MD
<br />25 DID TOBAt o USE CONTRIBUTE TO THE DEATH?
<br />❑ YES I] NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />0103NOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF :DEATH
<br />24d. TIME PRONOI ODED DAD
<br />24e. On the basis of examination andtor investigation, in opinion death occurred at
<br />the time, date and place and due to the cause(s) stated (Signature and Two
<br />28a. HAS ORGAN OR; r • ATION SEEN CONSIDERED?
<br />® YES ■
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settle, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28b. WAS CONSENT GRAN':TSD
<br />Not Applicable if 28a Is NO Iii YES
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day* Yr.)
<br />June 27, 2018
<br />
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