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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 DEPOSITORY. FOR VITAL RECORDS
<br />ti ATE OFISSUAliCE
<br />7/23/2021
<br />LINCOLN, NEBRASKA
<br />202302658
<br />07/Cot
<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 />t. DECEDEars-NAME; (First, Middle, Last,
<br />Affl .] R rj
<br />Suffix)
<br />4. orrYANDsTATacm TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />8a. PLACE OF DEATH
<br />HOSPITAL. va Inpatient
<br />Q ER/Outpatient
<br />❑ DOA
<br />F SOGAL SECURITY NUMBER
<br />506.52-810
<br />8b. FACILITY -NAME Of not Institution, give street
<br />CHI Health St. Francis
<br />number)
<br />8c:; CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803 ,
<br />9a.RESIDENCE-STATE
<br />Nebraska
<br />9d ; STREET AND PU,#MBER, •
<br />428 S. WWodlan ( Dr
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER'I DAY
<br />MOS.
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />108. MARITA STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />D Married, but separated. 0 Widowed ; 0 DIvorced 0 Unknown
<br />11..FATHERS-NAME {First, Middle, Last, Suffix)
<br />MISSH Bamard
<br />13?EVER IN;U,S ARMED: FORCES? Give dates of service If Yes.
<br />(Yes, No, •or link.) NO
<br />15. METHOD OF DISPOSInON
<br />Eurial . Q Donation
<br />Cremation Q Entombment
<br />Removal: © Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />RUNS.
<br />3. DATE Of'DEA IIAo., Daffy#Yr,
<br />July 1,4202.:'.1:
<br />6. DATE OF BIRTH (Mo., Day Yr.)
<br />February 1, 194•
<br />1..
<br />Hospice FScllity
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />tOb. NAME OF SPOUSE (First, Middle, Last Suffix) If wife, give maiden ria
<br />David , M Rau Ill
<br />14a. INFORMANT -NAME
<br />David M Rau III
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surnaune
<br />Rhoda •E Hall
<br />16b. LICENSE NO.
<br />17a FUNERAL, HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />t ivingston-Sondemiann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska•.
<br />CAUSE OF DEATH (See instructs
<br />CITY / TOWN
<br />Grand Island
<br />6g. I�lS#ia6 Cf€Y>LFMFT$
<br />YES
<br />14b. RELATIONSHIP' TO DECEDENT'
<br />Spouse
<br />16c. DATE:(Mo.,;Day, Yr)
<br />July 18».2021'
<br />STATE
<br />ska
<br />i f3a and examples)
<br />18. 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 on a line. Add additional lines I necessary.
<br />IMMEDIATE CAUSE:
<br />imidEDtATEOJI4IS6ism* `> ,.a)RespiratoryFailure
<br />disease 4r canpiflan nsultia¢
<br />tit death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially ilst:condroons, if b)Stroke
<br />any, iaamng to the "°°° listed
<br />a«a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />:Eitter,the.UNDi�tI.YENttcause -o)AdenocarcinomaOf Lun
<br />g
<br />S PRP,* Iflury that Initiated
<br />the events resulting'in-death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Malnutrition
<br />APPROXIMATE INTERVAL
<br />onsetto death <.
<br />ImtT ediate
<br />8.:PART ll OVER SIGNFFICANT CONDITIONS -Conditions contributing to the death but not real
<br />C niftirt CbiSs
<br />20. IF FEMALE:;
<br />Not pregnant wi hin pMBt year
<br />Cl Pregnamstnrneotdaatp
<br />qt ❑: Natprefikknt, 514preinentwgnin 42 days of death
<br />•' ❑. Not pregnant, hid pregnant 43 days to 1 yea r before death
<br />0. Q unknown lrpre(ptaft within the past year
<br />B
<br />240, DATE OF:INJURY (Mo.,
<br />E 22d. INJURY AT WORK?
<br />❑YES NO
<br />21a MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Wean Iden
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. INA<
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July`14, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />ting in the underlying
<br />use given in PART I.
<br />21b. IF TRANSPORTATION
<br />Q Driver/Operator
<br />0 Passenger
<br />0 Padestrlan
<br />❑ Other (Specify)
<br />INJURY
<br />onset to death
<br />Months::.;:.;
<br />w WAS MEDICAL EIXAM!ERR' .•
<br />`
<br />OR CORONER CONTACTED?
<br />❑ YES, ®NO
<br />21c. WAS AN AUTOPSY PFORMi
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS I4YA(LAi3LI
<br />(
<br />TO'COMPLETE CAUSE OF DEATH?
<br />❑ YES
<br />OF INJURY -At homtt.farm, street, factory, office building, construCl
<br />23c. TIME OF DEATH
<br />aY �6, 2 1 __ . 02:04 PM
<br />C Tgtha bast pf ;awe knowledge, death occurred at the: time, date and place
<br />Slid ddatotlis':Is) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />TIME OF DEATH
<br />24d. TIME POUNCED DEAR, / .:...
<br />245.On the basis of examination and/or investigation, in my oomph des#) opcurrad at :...
<br />the time, date and place and due to the causes) steed. sod Tae)>. . <
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />28.0)a TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ,el NO 0 PROBABLY 0 UNKNOWN
<br />27 NAME, Ina ANO ADDRESS OF CERTIFIER (Type or Print) .., ,.
<br />MiChaei A0i',Ionner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES gg NO
<br />64 B k .
<br />28b. WAS CONSENT GRA'►N ED?
<br />Not Applicable If 26a Is NO ( YES . ❑ NO'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 19, 2021
<br />
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