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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTfrIES 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 />DATE OFISS(1ANCE
<br />12/7/2020
<br />LINCOLN, NEBRASKA
<br />202605279
<br />?/..? J.Cat.r
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald Lee Rathman
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Prosser,.Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />50844-6098
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />0
<br />U
<br />8b. FACILITY-NA'ME ( fret Institution, give street and number)
<br />CHI Health St Francis
<br />Sc;CITY OR TOWN
<br />Grand Island
<br />OF DEATH (Include Zip Code)
<br />68$03
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />84
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8s. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />20 17131
<br />3. DATE OF DEATH.(i10.,OS%>le).
<br />November 22, 2020. ::
<br />S, DATE OF BIRTH1(Mo., Day Yej
<br />October 5,:,1936..
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Sd. STREET AN4NUMBER
<br />5fl2 West; Lowry Road
<br />1Da 61ARITAL.STATUS AT TIME OF DEATH O Married 0 Never Married
<br />0 Married, but separated 0 WIdowed 0 Divorced 0 Unknown
<br />Se. APT. NO.
<br />ff. ZIP CODE
<br />68832
<br />9g rot,.
<br />YES NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Laveda Mae Kroeger
<br />11. FATHER S-NAME (First, Middle, Last, Suffix)
<br />Meaner Rathman
<br />(12. MOTHER'S -NAME (First,
<br />Norma Bourg
<br />Middle, Maiden Surname)
<br />13.`EVER IN U.S. ARMED- -FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/16/ 956-12/05/1961
<br />15. METHOD OF DISPOSITION
<br />®' Bu)lai ❑ Donation,
<br />❑<CrematIon ❑Entombment
<br />Removal ❑Other (Specify)
<br />14a. INFORMANT -NAME
<br />Laveda Mae Rathman
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranio
<br />16b. LICENSE NO.
<br />1071
<br />14b. RELATIONBFHP TO DECENT:;
<br />Spouse
<br />18e. D I,TE
<br />December'? 2020
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cedarview Cemetery
<br />CITY / TOWN
<br />Doniphan
<br />STATE
<br />Nebraska
<br />yrii, FUNERAL:HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Fantle FuDE ral dome, 2929 S. Locust Street, Grand Island, Nebraska
<br />1Tb. zip coda
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />ie. PART I. Eiger the chain of events- -diseases, Injuries, or complleefbesthat directly caused the death. DO NOT sneer terminal events such as cardiac erred,
<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 />I Moot * CAUSE (Finest a) COVID-19 Infection -
<br />dblgksa or condition resulting
<br />Sequentially Itst conditions, If
<br />any, legging to the r.autieRebid
<br />eniitle a......
<br />EMpr the UNDERLYING CAUSE
<br />(diseees or injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />APPROXIMATE INTERVAL
<br />onset to death.
<br />Days
<br />onset to death
<br />onsetitcdeatii
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />1 & PART fl OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the Underlying cause given in PART I.
<br />Atrial Fibrillation, Congestive Heart Failure, Coronary Artery Disease
<br />20 IF.:FEMALE >.:
<br />lint pregnant within gut year
<br />❑ ;Pregnant at dine of sMslb:'
<br />❑ Not Osamiah butpn linant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0: unknown if.ptegnaig wtihin the past year
<br />22s<DATE OF I
<br />JURY (Mo;;Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES NO:::.:
<br />2�1aI. MANNER OF DEATH
<br />Ia! Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14. WAS MEDICAL EXAMINER
<br />OR CORONER.CONTACTE0?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED.?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY`RINDMIGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q.;.NO ..::.-.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f 1::OCA'1ION OF INJURY`:;: STREETS NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 22, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 3. 2020
<br />23e. TIME OF DEATH
<br />09:25 AM
<br />234 YO Ow best of thy knowledge, death occurred at the time, date and place and dui to the muesli) stated. (Signature and Me)
<br />Chad Vieth, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES ixj NO u PROBABLY 0 UNKNOWN
<br />At
<br />W
<br />o g
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />2tP.;CODE ;.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />34e. 4n the basis of examination and/or Investigation, In mti Opinion Mbth. dctu ed at
<br />thetas*, date and piece and due to the causels) stated. (Signature 4 'TNIo)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES : ®NO
<br />27 AIAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, M10, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?;:....
<br />Not Applicable if 26a is NO Q YE13
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 4, 2020
<br />
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