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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTII*, = W�IICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DATE OF ISSUANCE
<br />APR 14 2005 TAN�Ers. COOPER
<br />AfmsTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
<br />200503509
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUHRGRT
<br />CERTIFICATE OF DEATH O 5 04086
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo.. Day, Yr.)
<br />_ - --._.. ... le onald Allen Denn,hardt M April 3., 2005 a _ _ _
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER I DAY 6. DATE OF BIRTH (Mo. Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MIN5.
<br />Carrol, Iowa 72 August 30, 1932
<br />7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br />507 -34 -5768 HOSPITAL: J Inpatient OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CXER /Outpallent ❑Decedent's Home
<br />St. Francis Medical Center U Dok ❑ Other (Specify)_-
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH
<br />Grand Island Hall
<br />9a. RESIDENCE -STATE 9b.000NTY
<br />n9cCITY R T . Nebraska Hall rand Island
<br />9d. STREET AND NUMBER 9e. APT. NO 9f. ZIP CODE
<br />804 S. Sycamore 68801
<br />ioa. MARITAL STATUS AT TIME OF DEATH I[Marrled U Never Married [10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />L]Marded, but separated UWidowed ❑Divorced 0Unknown Joy G. Tooley
<br />11. FATHER'S -NAME (First, Middle, Last, ! Suffix) 12. MOTHER'S -NAME (First, Middle
<br />Clarence W. Dennhardt Bertha
<br />13. EVER IN U.S. ARMED FORCE57 Give dates of service If yes. 14e, INFORMANT -NAME
<br />(Yes,no,orunk,) Yes: 2/10/53 2/7/55 Joy G. D- annhardt
<br />15, METHOD OF DISPOSITION 16a. EMBALMER- SIGNAT�t-RE 16b. LICENSE NO.
<br />L]BUdal ❑Donation NOt Embalmed
<br />XCremation ❑ Entombment i6d, CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN
<br />U Removal U Other (Specify) Westlawn Crematory Grand Island
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE
<br />9g, INSIDE CITY LIMITS
<br />XJ YES U NO
<br />,/ Maiden Surname)
<br />Oenba.rdt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />April 6, 2005
<br />STATE
<br />Nebraska
<br />18. PART I. Enter the chain of events - •diseases, injuries, or complications - -Ii 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 />IMMEDIATE CAUSE (Final (a) Coronary Artery A t h e r o s c l e r o 3 i s 1.
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />(b)
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(c) --
<br />17b, Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />I
<br />I
<br />onset to death
<br />minutes
<br />I onset to death
<br />I
<br />I
<br />I _
<br />I onset to death
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resultIng In the underlyIng cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />Hypertension
<br />20, IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />U Unknown if pregnant within the past year
<br />OR CORONER CONTACTED?
<br />Ll YES Ll NO
<br />21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />X7 Natural U Homlcide ❑ DrivarlOperator �(
<br />❑ El YES l] NO
<br />Passenger
<br />❑ ACCldentL] Pending Investigation _.._ ._ ......._
<br />❑ Suicide IJ Could not be determined El Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />L] Other (Specify) COMPLETE CAUSE yyOFDEATH?
<br />❑ YES C1 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />n
<br />22d. INJURY ATWORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES U NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/rOWN
<br />STATE ZIPCODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) z 24a. DATE SIGNED Mo., Da Yn) 24b, TIME OF DEATH
<br />�y ��� D4/07/�Z00 20:57 m
<br />PATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH s 24c PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />e°z m FSM�a� 04/;03/2005 20 :57 m
<br />°u
<br />-0 23d. To the best of my knowledge, death occurred at the time, date and place r` w: 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />S 2 and due to the cause(s) stated. (Signature and Title ) V p p the time, date and place end due to the cause(s) stated. (Signature and Title)
<br />4 12 0 ce
<br />a aim
<br />25. DIDTODACCO USE CONTRIBUTETOTHE DEATH? 26a, HAS ORGAN OR TISSUESY DONATION BEEN bONSIDERED? . WAS CONSENT GRANTED?
<br />4 U YES ❑ ND ❑ PROBABLY Y`] UNKNOWN ❑ YES LJ NO Not Applicable II 26a is NO ❑ YES ❑ NO
<br />27. ME,
<br />Iar T TLE / D ADD ESS OF CERTIFIES (PH 5 IAN RONER'S PHYS�I I iN R COUNT �ATTORN ) e or rm°
<br />ou o orny, Locust, Grand Island ii L 68801
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />°lxt'�„ APR 12__200
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