|
��Q��1110�1�11(lyryy�i, 4i
<br />ASPro11t1911 o �1 rpgy , 't i 111111tHppi d�1�r�i
<br />?`�i1i)rliiliii�l�l T�lVi4�Jii) �)Jil�77k(r�rlr„.n`��d111111(lllS�eP rf��wpr�,
<br />STATE OF NEBRASKA
<br />u1111111111��
<br />v�: Z i(\11117111111 0y ,,,a1e,M/IG IAg1,1'1111IOE,'.
<br />lagW
<br />LhMJ, 1t�, ��PIIIIIIIIJt�" trrudltts
<br />4(1t411111liitt! c .
<br />WHEN TH#S COPY CAI "RIES THE RAISED SEAL OF STATEOF NEERASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TiRUE COPY Oi I; WJE ORIGINAL RECORD ON FILE WITH TILE NEBRASKA LDEFARTMENT OF HEALTH AND
<br />UMAN SERVICES, RTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR* FOR VITAL RECORDS
<br />DATEOF IISSuAttCE
<br />8;312023
<br />INCOLN, NEBRASKA
<br />X02304119
<br />B
<br />ASSISTANT STATE REGIS'
<br />i DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 17E1 EDEare -hAitE {Firstt, Middle, Last, suffix)
<br />)iak pale Ftouienbaugh
<br />4 CITYAND'ATEZORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />nd Island, Nebraska
<br />i+SOCIAL aggindr: HUMBER
<br />50548.5297
<br />8 FAdLITY,NAME:t0 hot Institution, street and number)
<br />407 N. Sherman Ave
<br />(include Zip Code)
<br />tis
<br />AGE LaatBlrthd*y
<br />(Yrs )
<br />Bb.UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a Ft AOE OF
<br />DES1B„
<br />HOS A ( 1nijatisnt
<br />0 EROutpattent
<br />❑:DOA
<br />2. SEX
<br />Male
<br />8a 1 etiloi CE417vta
<br />Nebraska
<br />9b. COUNT(
<br />Hall
<br />8d $TR... TAND moats
<br />407' H ierman Acre
<br />18e M RJTAI. STMUS:AT TIME OF DEATH El Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />114.47111.1f111414910. (Mott Middle, Last, Suffix)
<br />Vernon Rpdei baugh
<br />13.;£(/Eit IN i! S ARMEtf pt>Ii2CE84 Give tat of service If Yes.
<br />'0$ 0.3, or Unk.)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1B. ttETHOD OF1:92.00801014
<br />t smoN
<br />0 Btulsl ❑ Donation
<br />cremated ®Entad brnent
<br />112emoval' ❑ (Spy)
<br />--���
<br />9c. CITY OR TOWN
<br />Grand.. island
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nurshm HometLTC
<br />®
<br />DacedenesMotte
<br />0 Other (SP Y)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />Ba APT. NO.
<br />1Ob. NAME OF SPOUSE (FIT Mdthe, Le
<br />Darlene Linden
<br />12 MOTNEWS-NAME (Fist, Middle,
<br />Donna Benson
<br />14a. INFORMANT -NAME
<br />Darlene Rodenbaugh
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />174L:FUNERALHOMENAME AND MA LISADDRESS (Street, City or Town, Stale)
<br />alt 1}alths uneral glome, 2929 S. Locust Street, Grand Island,: Nebtastra
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See inetniCtIons 4nd examples)
<br />18. PART I. Enter *Oohe % of events-.dbaasw, injuries, or compacatlons4het directly caused the death. DD NOT enter ta UewMs suiting cardiac ate,
<br />respiratory amt, or ventricular abdfallon without shouting the etiology. DO NOT ABBREVIATE. Enter only one cause on itline. Add additional linea necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pancreatic Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, B b)
<br />strr;.laadino to tap cause dated
<br />e UNtY,Bitt.YlNGetkitte2 C)
<br />tteasitithlititivattititittead
<br />ACONSEQUENCE'OF:
<br />pventa resullh+p H death)' DUE TO, OR AS A CONSEQUENCE OF:
<br />t en*8t:ti/t8
<br />$9.
<br />2.a tP i EMALE:
<br />t pregmntwuiilt past Inde
<br />ud atpnar ordsaar
<br />$leas, bed Ifteghant %Ven 42 Jaye or 4
<br />anent, but preened 4e days to 1 year baron death
<br />await premataatleht the peat year
<br />i
<br />:DATE.
<br />MiJURY (Mo€ Day, Yr.)
<br />22d. INJURY AT WORK'
<br />AYES .❑NL)
<br />21a. MANNER OF DEATH
<br />Natural El Homicide
<br />0 Accident ❑ Pending hwestlgstlon
<br />ukide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF MJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />24tx IF TRANSPORTATION INJURY
<br />© t rIOpetator
<br />❑ Pasenger
<br />lPedestrian
<br />:.:❑ Other (Specify)
<br />21c. WAS AN
<br />❑ YES lipN
<br />21d MASA
<br />TO t_ _
<br />0 YES
<br />t 80=h -ram, street, factory. office bulkjng, comoruCtIon
<br />INJURY"= STREET & NUMBER, APT.NO. CITWTOW N
<br />23a. DATE OP'DEATH (Mo., Day, Yr.)
<br />Novent,ter 29, 2018
<br />23b. DATE ED (Mo, Day, Yr.) ' 23c. TIME OF DEATH
<br />(`iDyeml�¢r=40. 918 09:57 PM
<br />.IA1.0* bt8t or mY knowledge, death occurred at the time, date and place
<br />;atldduatotbe:cawse(a) stated. (Signature and Title)
<br />Tyler J. Vettel, MD
<br />STATE
<br />24a. DATE SIGNED (Mo.. Day. Yr.)
<br />24c, PR4NVOUNCE(f DEAD (Mo., Day, Yr.)
<br />,:pn the task of examination ander iaveaegetton, In my apMWO &WM"
<br />lc"
<br />:1taoiErita, date and place and deur to the gauss(*) stated. gtignatsse- ?..
<br />D TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />S
<br />.0 No . ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN
<br />❑ YES
<br />R TISSUE DONATION BEEN CONSID
<br />Ii" N ME itsANPA esillOFCERTIFIER(Type orPrint s
<br />yler J. Vettelt MD, 2116 W Faidley Ave Ste 400, Grand Island, Nebraska, 88803
<br />ED?
<br />Vt. WAS
<br />,pHcabte ff 28s Is NO
<br />28a REGISTRAR'S SIGNATURE,.-_. �rrrv.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 6, 2018
<br />
|