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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />a SYSTEM, IT CERTIFIES THE BELOW TO BE TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS _SECTION, -WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =
<br />DATE OF ISSUANCE N'
<br />Z005 TANLEY-S. CODPWR
<br />MAR 0 12005 ASSWAAFT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HeA4 AND HUMAN SEEP VICES
<br />200502535 -
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<br />• STATE OF NEBRASKA- DEPARTMENT OF' HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT��
<br />CERTIFICATE OF DEATH- _ �501880
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
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<br />Emil Rudolph Man elsen Male February 14, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 56. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr,)
<br />Grand Island, Nebraska (Yrs.) 71 MOS. DAYS HOURS MINS. Nov. 20, 1933
<br />'1 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505 -36 -3539 HOSPITAL' ❑Inpatient OTHER' UNursingHome /LTC U Hospice Facility
<br />8b. FACILITY•NAME (If not Institution, give street and number)
<br />❑ ER /Outpollent Decedent's Home
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<br />Home: 208 E. 14th 5t. • DC4 U Other (Specify), -
<br />`•'ti Y 8c. CITY OR TOWN OF DEATH (Include Zip Code) ad. COUNTY OF DEATH
<br />Grand Island 68801 Hall
<br />ga. RESIDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />- - --
<br />9d. NUMBER
<br />2 9e. APT. NO 91. ZIP CODE
<br />0P 8E E. 14th St. 68801
<br />i Oa. MARITAL STATUS AT TIME OF DEATH f[Married U Never Married lob. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name.
<br />❑ Married, but separated ❑Widowed ❑Divorced ❑Unknown Helen Elsie Halstead
<br />9g. INSIDE CITY LIMITS
<br />AJ YES U NO
<br />11. FATHER'S-NAME (First,
<br />Middle, Last, Suffix)
<br />12. MOTHER'S-NAME
<br />(First,
<br />Middle, Malden Surname)
<br />.... ....... - August
<br />Mangelsen
<br />- _ ., ..._............
<br />Elise
<br />Kruse
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />14a. INFORMANT -NAME
<br />� - t6 US
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<br />141b. RELATION$HIP TO DECEDENT
<br />(Yes,no,orunk.) NO
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<br />Helen Mangelsen.
<br />__
<br />23c. TIME
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<br />Wife
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER- SIGNATURE
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<br />16b. LICENSE NO.
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<br />16c. DATE (Mo Day, Yr. )
<br />February 18,
<br />aBurlal ❑ Donation
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<br />�' 200.
<br />• Cremation ❑ Entombment
<br />16d. CEMETERY, REMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />STATE
<br />•Removal ❑ Other (Specify)
<br />Westlawn Memorial Park Cemetery
<br />Grand
<br />Island, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. Stale) 17b. Zip Code
<br />Apfel Funeral Home, 1123 West Second, Grand Island, Nebraska 68801
<br />18. PART I. Enter the Chain of events- Alseases. Injuries, or Complications- -that directly Caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillallon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1
<br />IMMEDIATE CAUSE: 1 onset to death
<br />I
<br />IMMEDIATE CAUSE (Final (a) Cardiac arrest I 5 minutes
<br />disease or condition resulting DUE T0, OR AS A CONSEQUENCE OF: 1 onset to death
<br />In death)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF;
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(cilseaseor In] ury that Initlated (o)
<br />the events resu hng In eat DUE TO, OR AS A CONSEQUENCE OF-
<br />LAST
<br />(d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS�Conditions contributing to the death but not resulting in the underlying cause given In PART I
<br />20. IF FEMALE:
<br />U Not pregnant within past year
<br />U Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />U Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OFDEATH 21b.IFTRANSPORTATION
<br />IlNatural ❑ Homicide ❑ Driver /Operator
<br />❑ Accident❑ Pending Investigation LJ Passenger
<br />❑ Pedestrian
<br />I onsetto death
<br />I
<br />I
<br />I onset to death
<br />I
<br />1
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />)6J YES U NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />U YES U NO
<br />❑Suicide U Could not badetermined 21d .WEREAUTOPSYFINDINGSAVAILABLETO
<br />❑Other (Specify) COMPLETE CAUSE OF DEATH?
<br />❑ YES Y0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b TIME OF INJURY 22c PLACE OF INJURY-At home, farm, street, factory, office building construction site etc. (Specify)
<br />m
<br />22d. INJURY AT WORK, No. DF,SCRIBE HOW INJURY OCCURRED
<br />L1 YES U NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT, NO, CITY/TOWN STATE ZIP CODE
<br />Z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a
<br />24a DATE SIGNED (Mo., Day�Yr.)
<br />24b. TIME OF DEATH a p p r o x
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<br />a�
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<br />10:30 pm m_
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<br />23b. DATE SIGNED (Mo.,Day,Yr.)
<br />__
<br />23c. TIME
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<br />24c.PRONOUN p' EAD(Mo.,Day,Yr
<br />24d IME PRONOUNCED DEAD
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<br />oand
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />due to the causes) stated. (Signature and Title) ►
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<br />24e. On Ih s of a urination an Inv sl 8tioit, in o ion death oocurred At
<br />the if date a d and d to t us a) s to and Title )
<br />¢
<br />; place ,(Signature
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<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26 AS CONSENT GRANTED?
<br />'
<br />U YES ❑ NO U PROBABLY L'r UNKNOWN
<br />❑ YES
<br />X4 NO
<br />_ TTf
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27 NAME, TITLE AND ADDRESS OF CERTIFIER PHYSICIAN, CORONER'S PHYSIC IAN OR
<br />S 131
<br />COUNTY ATTORNEY) (T pe or Print
<br />NE
<br />e D Dubbs GIPD S Locust,
<br />Gran
<br />Island, 68801
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<br />28a. REGISTRAR'S SIGNATURE
<br />281b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 2 005
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