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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT°®E
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE AI
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITIOR,.
<br />DATE OF ISSUANCE
<br />04/22/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND.
<br />202306/15
<br />trGR 1 tr-twen 1 G tar Los^ 1.3-4 . `_
<br />-
<br />eti 2
<br />♦s.
<br />To be comp by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS -NAME (First, Middle, Last. Suffix)
<br />Vera Mae Rathman
<br />xA y P h
<br />- ".r. %
<br />aa - • �, b.8., Day, Yr.).
<br />..
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5.. AGE - Last Blrthday
<br />Sb. UNDER 1 YEAR
<br />50 vt : 1Fu
<br />Ey r' ¢F 1 " I Qayr V4.7
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />r :
<br />*fA
<br />14 ""
<br />'October 31, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />506-32-8470
<br />8a. PLACE OF DEATH
<br />HOSPLTAL [] Inpatient OTHER h 1'Nursing Horne/.TC ❑ Hospice Facility
<br />8b. PACILTfY.NAAINE (It not trlstltutton, give sbeetandnunib8t)
<br />..Wedood bare Center
<br />- Q ERIOutpaaent ..` - Q Dtgedeit's Home -
<br />D. . t Dourer (speeffy) .
<br />asCITY OR TOWN. OP DEATH (Include Zip Code) •
<br />Grand Island 68603
<br />.
<br />_ -
<br />' .
<br />^8d. COUNT( OF DEATH T,. ) .: -a
<br />9e. *ESIOENCE-STATE
<br />Nebraska
<br />As COUNTY
<br />Hall
<br />9c. col ORTGI AAl
<br />GraIB1s)and
<br />9d. STREET AND NUMBER
<br />1414 S. Harrison Street.
<br />APT. NC(';
<br />, .
<br />ZIP coos
<br />68803
<br />eg. =tog Ci3Tr LI MITS
<br />r VES Q NO
<br />10. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Mani
<br />0 Married, but separated Q Widowed 0 Divorced 0 Unknown W
<br />101s. NAME OF SPOUSE (First, Middle, ' Cast,' Suffix) if wife, glve maiden name
<br />Elton, •H . Rathman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Floyd . Garrison
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Nora Engel .
<br />13. EVER IN U.S. ARMED FORCES? Give dates or service ff res.
<br />(Yes, No, or tins.) No
<br />14a. INFORMANT•NAME
<br />Elton H Rathman •
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband _._.
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ■ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />186. LICENSE NO.
<br />16.. DATE (Mo,. Day, W.)
<br />Apri117, 2015
<br />®Cremation Q Entombment
<br />❑ Removal 0 Other (Specify)
<br />1ed. CEMETERY, CREMATORY OR OTHER LOCATION CITY/ TOWN .. . STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City er Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17bt250 Code _
<br />68801
<br />1
<br />CAUSE OF DEATH (See instructions and examplesi _
<br />To be completed by: CERTIFIER �
<br />,
<br />18. PART I. Enter the ;halts of events -.diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events each as cardlac arrest, ' APPROJUIRATE 1HITER AL :
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO N07 ABBREVIATE. Pyr orgy one cause on a. One. Add addalonal tines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pings a) End Stage Alzheimers Dementia
<br />disease Cr condittofl resulting
<br />. _ -- . .. `
<br />onsa tO Oath. , :
<br />10 Yetis -......
<br />in deathDUE TO, OR AS ACONSEQUENCE OF: ..:: _
<br />Sequentially fist condhioas, If b) Chronic Cerebrovascular Disease -
<br />any, leading to the cause limed
<br />a On6StT6 Md�[ (
<br />0e a a' DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onsett0 dean'
<br />.�.. .
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: $ 'onset%sle*Qt`
<br />LAST d) I _ ..
<br />-
<br />18. PART II. OTHER SIGNIFICANT CONDrONS-Concotlons contributing to the death but not resulting in the underlying cause given In PART 1.
<br />1S. VAS -MEDICAL 6iA/SHER •
<br />oe caner Rr414fACtserl: --
<br />DVES a .:
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />11 Natural 0 Homicide
<br />Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 DriverIOpetator
<br />0 Passenger
<br />21c.WAS ANAUTOPSY.PEIt'ORMt ,-:
<br />YES ®. NO .. ._ ..
<br />. . .
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />0 Accident 0
<br />0 suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSYANDINGSAUAILABLE4
<br />TO COMPLETE -CAUSE OF DEATH? t.
<br />- ... _ ... ..
<br />0 YES _ 0 N0.:
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, faun, street, taotory, office building, construction sits, etc. (SpecIfy)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED -
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 16, 2015
<br />To be completed by
<br />CORONETS PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED pito., Day, Yr.) 1
<br />24b. TIMEOF DEATH,
<br />23b. DATE SIGNED (Mo., Day, Yr.) t
<br />April 16, 2015
<br />23c. TIME OF DEATH
<br />03:30 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOU ED DEAD
<br />i 8d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(a) stated. (Signature and Title)
<br />Steven Husen, MD
<br />24e. On the bests of examination and/or investtguron, In my opinsendeata seemed at
<br />the time, date and place and due to the causes) stated. (siwre tera.snd'R8e)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR T
<br />YES il NO 0 PROBABLY 0 UNKNOWN 0 YES
<br />DOkiATI054'.-BEEN CONSIDERED?
<br />•
<br />256. WAS CONSENT ORANThia? :. ., .'
<br />Not Applicable 125a is NO ri YES .,NO
<br />27. N ME, TITL AND ADDRESS OF CERTIFIER (Type or Prin - -
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 . , :. ._ , .
<br />r
<br />29a REGISTRAR'S SIGNATURE /jam_
<br />28b. DATE FILED BY REGISTRAR (Mw, 08ji �!a►
<br />April 20, 2015
<br />
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