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STATE OF NEBRASKA
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<br />W EN: TF1 S:.0 i ?Y; ARR/ES THE RAISED SEAL OF STATE OF NEBRASKA; IT CERTIFIES THE DOCUMENT BELOW TO
<br />A>T`RUE coey0f THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA . (DEPARTMENT OF HEALTH AND
<br />HUMAN'.SERVICES .VITAL RECORDS OFFICE, WHICH IS THE LEGAL:DEPOSITORY FOR VITAL RECORDS
<br />Or
<br />E
<br />8
<br />BATE OF ISSUANCE
<br />2/13/2024`
<br />LINCOLN, NEBRASKA
<br />202.406271
<br />3104 180440
<br />SARAH BOHNE KAMP
<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 />1.: ECEDEN7`S-NAME :(First, Middle, Last, Suffix)
<br />IarY> do`= ROdet baugh
<br />4::CITTANb STATE::OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />O'Neill, Nebraska
<br />7,;SOCIAI SEQUR)TYNUUMBER
<br />'<:508 924090:;
<br />BbaFACILITYA AME:(if not Institution, give street and number)
<br />CHI Health Nebraska Heart
<br />sa,,:o ry 9R;TOWNOF:DEATH (Include Zip Code)
<br />'Lincoln 685 fi
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d;: STREET-mip NUMBER
<br />142:1'=N Vrna`Street
<br />9b.000NTY
<br />Hall
<br />5a: AGE - Last Birthday
<br />(Yrs.) ..
<br />61
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Fern ale
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />t ea: PI; ACEOF DEATH
<br />HOSPITAL E inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />24 01750
<br />3. DATE OF o*tlTti (Mo DaV:Y.
<br />February' 4 ,2*2 .;.:'...
<br />6. DATE OF Sift 7H (Mo:
<br />February„6, 1:962
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />'topics Fsiiity
<br />€�st�t8sij»;i~i
<br />JROTA.
<br />.
<br />ltiti MANITAL;'STAT#IS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated [] Widowed ❑ Divorced 0 Unknown
<br />1:0b. NAME OP SPOUSE (First, Middle, Last, Suffix) If wife, give maWen nitfll '
<br />Marty Rodenbaugh Sr
<br />11. FA:TMER'S.NAME„(€#rat, Middle, Last, Suffix)
<br />Tim. !: McGaf in:'.'
<br />13;;;EVER IN:U:S: ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or link ) NO
<br />11Z MOTHERS -NAME (First, Middle, Malden Surname
<br />Jennie .:° Strong
<br />14a.INFORMANT.NAME
<br />Marty Rodenbaugh Sr
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑:Donstion.
<br />eradiation [ Entombment
<br />❑;Ftatnot(a(:>:> 0 Other Mowry)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO,
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION .:; CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faith Funea( Home 2929 S. Locust Street, Grand Island,Nebraska
<br />CAUSE OF DEATH (See instructions: and examples)
<br />sea, PART i. Enter the ;hale 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 if necessary.
<br />IMMEDIATE CAUSE:
<br />IMiED kT8catiattain i>"!:.: a)Multi organ failure
<br />tteati.I DUE TO, OR AS A CONSEQUENCE OF:
<br />seyuentlsny got conditions, B b)
<br />any, leading to the caua listed
<br />on liiu's: . , .....
<br />Bitter ttN::UNDEIt*.: lNG CAUSi
<br />(ilbrsstia:o? Ingity:thiginithited
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />IS=:PARTII, OTNE10:94DIEPICANTCONDlTIONS-Conditions contributing to the death:but nOresult)ng ip tit :underlying cause given In PART I,
<br />Disserriihated; IntravaScular coagulation, Acute Massive Pulmonary Embolism, Cardiomycpathy
<br />16c. DATE (Mo., Day, Yr.,) ..
<br />Februatj 7,: 024
<br />Nebraska
<br />.7b. Sip.
<br />APPROXIMATE
<br />onset o cliNdh
<br />Davy:;;;;
<br />onset to death
<br />TERVAL
<br />49. WAS IIICAL EXAMINER' >!
<br />OR COROrsiE coarraxr.TED? .:
<br />OYES fia NO
<br />20. IF FEMALE:
<br />E Nat:p/egneat with ln'.put
<br />cyPrilliiiiint hi'iiene;ufde0;
<br />Nbt:ptsgnsn bu't prspnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pragna f within the pest year
<br />221r DATEOF INJU
<br />22d-'INJURY AT WORK?
<br />OYES ❑ NO
<br />Day, Yr.)
<br />21a. MANNER OF DEATH
<br />E Natural ❑. Hothic.kie.:.:
<br />❑ Accident ❑ Pending Inuestigebon`i
<br />❑ Suicide ❑ Could not be detarininiid:
<br />22b. TIME OF INJURY
<br />210,.IF TRANSPORTATION INJURY
<br />:0 finyer/Operator
<br />:.❑ Paaenger
<br />0. Pedestrian
<br />❑ Other (Specify)
<br />21c. WASANA
<br />0 YES
<br />Y P!Ef(F0RMRDy
<br />NO
<br />21d. WERE AUTOPSY>ROWS AVA1LASLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ;
<br />22c. PLACE OF INJURY -At I(othri, farm, street, factory, office building, constructltnf $
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22E„ LOCATIQAI:,QF INJU((Y:; STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a.'DATE OP DEATH (Mo., Day, Yr.)
<br />February 4, 2024
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Febriia v::6. 2024 12;18 PM
<br />ale. To#tie beet of my knowledge, death occurred at the time, date and place
<br />.5fl4 duo titbit Omits) stated. (Signature and Title)
<br />Rani Balasubramanian, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEATH
<br />MPocioe
<br />24d. TIME)PRONOuNCED DEAD
<br />24e. ph the basis of examination and/or investigation. In my opinion death 44c1ltretf st ..
<br />the.tims, date and place and due to the cause(sl stated. (*I9nat"04:41de) :.:::....
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />:❑'YES ,:;;;( NOfl PROBABLY ® UNKNOWN
<br />27 :IAAME,:TITGE:AND:ADORESS OF CERTIFIER (Type or Print
<br />Rafri<Balasubrarranian, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />285, REGISTRAR'S SIGNATUREC7
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES . .:NO
<br />26b. WAS CONSENT GRANTED?;::,
<br />Not Applicable If 26a Is NO ".>::<❑:YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 8, 2024
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