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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SFCTIO4_1,_ WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. y DATE OF ISSUANCE MAR o 12005 rANtEY S. COOPER ASSISTANT -STATE REGISTRAR . LINCOLN, NEBRASKA HEALTFI=.AND HUMAN SERVICES' 200503439 STATE OF NEBRASKA -- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANDSUPPORT - CERTIFICATE OF DEATH 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) Emil Rudolph Man elsen Male February 14, 2005 1�14, 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo , Day, Yr,) g Grand Island, Nebraska (Yre.) 71 MpS. DAYS HOURS MINS. Nov. 20, 1933 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH 505 -'36 -3539 _ FIOSPJTAL! ❑ Inpatient OTHER: ❑Nursing Home /LTC ❑HospiceFacllily t 81s: FACILITY -NAME (IT-not instluffdn, givesfreel and number) ❑ ER /Outpatient Decedent's Home f Home: 208 E. 14th St. ] Ixn El Other (Specify) ...._ ( COUNTY OF DEATH 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed ` + Grand Island 68801 Hall 9a. RESIDENCE -STATE 9b. COUNTY 9c CITY OR TOWN A/ Nebraska Hall Grand Island 9d. STREET AND NUMBER 9e,APT.ND 91.ZIPCODE 9g. INSIDE CITY LIMITS 208 F 14th St. 68801 XI YES ❑ No 16a. MARITAL STATUS AT TIME OF DEATH Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name El Married, but separated ❑Widowed ❑Divorced ❑Unknown �elen Elsie Halstead 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Maiden Surname) August Mangelsen 1(i li. Elise Kruse 13, EVER IN U.S. ARMED FORCES? Give dates of serviced es. 14a. INFORMANT -NAME 14b. RELATIONSh.IP TO DECEDENT (Yes, nv, or unk.) No Helen Man elsen. } 23b. DATE SIGNED (Mo., Day Yr.) 23c.TIME OF DEATH s 24c. PRONOUN 'BEAD (Mo., Day, Yr 24d TIME PRONOUNCED DEAD Wife 15. METHOD OF DISPOSITION avurlal ❑Donation 16a. EMBALMER-SIGNATURE ~� 16b. LICENSE NO. 15.�r 16c. DATE (Mo., Day, Yr. ) February 18, 200. ❑ Cremation ❑ Entombment 16d. CEMETERY, REMATORY OR OTHER LOCATION CITY /TOWN STATE ❑Removal ❑ Other (Specify) Westlawn Memorial Park Cemetery Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code Apfel Fanera.l Home, 1123 West Second, Grand Island, Nebraska r 68801 18. PART I. Enter the cbaln LI evants•"diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, J� I respiratory arrest, or ventricular fib rlllatian without showing the atiology. DO NOT ABBREVIATE. Enter only one cause on a Itne. Add addltlonal IInas If necessary. " IMMEDIATE CAUSE, rte � I�ij� IMMEDIATE CAUSE (Final (a) Cardiac arrest 1, disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: AY' In death) Sequentially list conditions, If any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or Injury that Inlllated the events resulting in death) LAST (b) DUE TO, OR AS A CONSEQUENCE OF: I DUE TO, OR AS A CONSEQUENCE OF: ._._.._._- (d) _.. __........... . 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death U Not pregnant, but pregnant within 42 days of death U Not piegrlant, but pregnant 43 days to year baton deaiA U Unknown it pregnant within the past year - 21a. MANNER OFDEATH 21 b. I F TRANSPORTATION I &atural U Homicide ❑ Driver /Operator U Accident❑ Pending Investigation U Passenger APPROXIMATE INTERVAL I I onset to death I 5 minutes I I onset to death I onset to death I I I onset to death I 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? K] YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? U YES 6 NO L.j Sulclde C3 Could not be determined El Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY m 22d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED ❑Othu(Specify) I COMILETECAUSy&01DEATk:? .._._ ......_.- ......_ ❑ YES "CJ NO 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, eta. (Speolly) r ❑ YES U NO 22f. LOCATION OF INJURY- STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 1(i li. 23a. DATE OF DEATH (Mo., Day Yr.) x „ 24a. DATE 510yE (Mo , Day`Yr.) 24b.TIME OF DEATH a p p r o x z- 10:30 PmM } 23b. DATE SIGNED (Mo., Day Yr.) 23c.TIME OF DEATH s 24c. PRONOUN 'BEAD (Mo., Day, Yr 24d TIME PRONOUNCED DEAD IM, mo ®b 1 005 111: .5 m m S 23d.To the best of my knowledge, death occurred at the time, date and place o Lu x 24e.On th e s of a urination an my st atidn, in o ion death occurred at �' Ir. y to ¢ and due to the cause(s) stated. ( Signature and Title) 0 o p the tl , data e%d end d tot use) s �11,,91,n8lleand Title) f2 /place 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? HASORGANORTISSUyyEE�DONATIONBEENCONSIDERED7 26 ASCONSINTGRANTED? 126a, U YES ❑ NO Cl PROBABLY Cl UNKNOWN ❑ YES " LP NO Not Applicable If 26a Is NO ❑ YES ❑ NO ' 27. NAME, TITLE AND ADDRESS OF CERTIFIER PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (T pa of Print Sge D Dubbs, GTPD, 131 S Locust, Grand Is�and, NE 68801 28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 2 3 200� �I