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<br />
<br />STATE OF NEBRASKA
<br />
<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 RESOlftHJN:FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTif:$Siit;:f;ONrWRicH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. jvl!i-'~~U~- "
<br />JV~' !'TiJ&:j;~.fcOOffR'
<br />J AN 2 0 2006 2 0 0 6 0 16 0 2 ASSIs.TANTliTAfEifitJisitfAri
<br />LINCOLN, NEBRASKA HEALT.tiANoHuIiA#i SEBVicES
<br />.., - -:......~, -~...,':". ..
<br />.,7;:', ,-;.", ~..:::,.~j~~,.., .::~ ,.
<br />
<br />.__._~~~~_ O~:~BRASKA - DEPAR~~~;tF~~~;~N~ ~u~~N:~~v'cEf#~~~~~~~~,~u~t~D6 2 0.0_.4 3
<br />
<br />DECEDENT'S-NAME (Firsl, Middle, LaSI, Suflix) 2. SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />Michael Charles Roenfeldt Male Januar 6. 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH r;. AGE.Las-;S-;;;-hd;y 6. DATE OF BIRTH (Mo., Day. Yr.)
<br />(Yre.)
<br />Grand Island. Nebraska 62 February 14, 1943
<br />
<br />~
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-7801
<br />
<br />6a. PLACE OF DEATH
<br />
<br />H.05ElIAl.:
<br />
<br />o Inpallenl
<br />
<br />QIlJfB: Xl NurSing Home/LTC 0 Hospice Facility
<br />
<br />Bb. FACILITY.NAME (If "01 IMtltullon, give street snd number)
<br />
<br />o ER/Oulpatlenl
<br />
<br />o Decodent's Home
<br />
<br />St. Francis Skilled Care Center
<br />
<br />0=
<br />
<br />o Olher (SpecilyL..
<br />
<br />Bc. CITY OR TOWN OF DEATH (Includa Zip Code)
<br />Grand Island 68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />gl. ZIP CODE
<br />68803
<br />
<br />gg. INSIDE CITY LIMITS
<br />
<br />lO YES 0 NO
<br />
<br />ga. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />
<br />9d. STREET AND NUMBER
<br />
<br />_.~804 West W(i~gh__
<br />lOa. MARITAL STATUS AT TIME OF DEATH
<br />
<br />arried 0 Nevsr Married lOb. NAME OF SPOUSE (First, Middle, Lasl, Suffix) It wite, give maiden nama.
<br />
<br />o Married, but s.parated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Joann Berger
<br />
<br />11. FATHER'S-NAME (First,
<br />Henry
<br />
<br />Middle,
<br />John
<br />
<br />Lasl, Suflix)
<br />Roenfeldt
<br />
<br />12. MOTHER'S.NAME (FirSI,
<br />Mary
<br />
<br />Middle,
<br />Hazel
<br />
<br />Maiden Surname)
<br />Francis
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales 01 service If yes. 14a.INFORMANT.NAME
<br />
<br />No Joann Roenfeldt
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />o Donation
<br />
<br />
<br />16b. LICENSE NO.
<br />
<br />o Burial
<br />
<br />~~
<br />
<br />I/q~
<br />
<br />16c. DATE; (Mo., Day, Yr.1
<br />Jan. 10, 2006
<br />
<br />IS. METHOD OF DISPOSITION
<br />
<br />Xl Cremalion U Entombmenl
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island.
<br />
<br />18. PART I. Enter the ~.in..Q1.~--diseases, InjurIes, or compllcallons--that dlreotly caused the death. DO NOT enter terminal events such as cardIac arrest,
<br />respiralory arresl, or vanlricular fibrilla lion withoulshowing the etiology. DO NOT ABBREVIATE. Enler only one cause on a line. Add addilionallines if necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition resulting
<br />In dealh)
<br />
<br />(a)
<br />
<br />(1\ <t-~~ L
<br />
<br />es.-<, p "-~i t):..-6-(
<br />. .~~,../--+-
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />" I,j-
<br />
<br />Cc,....cC \I"\..~........'A...__.!:/OS-
<br />
<br />I onset 10 dealh
<br />I
<br />I
<br />I
<br />
<br />x' IMMWIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSEQUENCE; OF:
<br />
<br />Sequentially list condltlons,1I
<br />any, leading to Ihe cause listed
<br />on line a_
<br />Enter Ihe UNDERLYING CAUSE
<br />(disease or Injury that Inltleted
<br />the events resulting in death)
<br />LAST
<br />
<br />(b) (...,;) -'=_~_~~_
<br />DUE TO, OR AS A CONSEQUENCE; OF:
<br />
<br />&L\'J ~r~"
<br />
<br />I onset 10 death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onsello deelh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condilions contrlbullng 10 Ihe dealh but nol resulllng in Ihe underlying cause given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />k- OR CORONER CONTACTED?
<br />o YES ~.
<br />
<br />o Not pregnant within pasl year
<br />o Pregnanlal time of dealh
<br />U Not pregnant, but pregnanl within 42 days 01 deeth
<br />o Nol pregnant, but pregnant 43 days 10 1 year betore death
<br />U Unknown if pregnant within the past year
<br />
<br />21a. MA~~ OF DEATH
<br />.r 0'Natural 0 Homicide
<br />
<br />o AccidentO Pending Invsstigalion
<br />
<br />21b. IF TRANSPORTATION INJURY 2tc. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Oparator
<br />
<br />o Passenger
<br />
<br />o YES
<br />
<br />iJNo
<br />
<br />U Pedestrian
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLE;TE CAUSE OF DEATH?
<br />o YES :!l NO
<br />
<br />o Suicide U Could not be delermined
<br />
<br />o Other (Specify)
<br />
<br />o YES 0 NO
<br />
<br />
<br />22.p.... ~~Of IN.J,URYI.At neml!.t .fBfftj,.3~t, t8~~ory" c.flice blOlIdln-g, eonstrucHon :;Ite, stc. (Sp{Jcl~y)
<br />
<br />~~o.DATE r)F.l1>lJURY (Mo" Doy, yn -
<br />
<br />m
<br />
<br />22d. INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />SlATE
<br />
<br />ZIP CODE
<br />
<br />cl~
<br />
<br />
<br />24a. DAT~ SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
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<br />
<br />240. PRONOUNCED DEAD (MD., Day. Yr.) 24d. TIME PRONOUNCEOD DEAD
<br />m
<br />
<br />24e. On tl1e basis of examination and/or investigation. in my opinion dealh occurred at
<br />Ihellme, dats end place end due 10 Ihe causers) slaled. (Signature and Tille) "
<br />
<br />26b. WAS CONSENT GRANTED?
<br />K
<br />Not Appli:~~.!.",~.;!.6_a!.~_NO 0 YES 0 NO
<br />
<br />vol,. Ne-
<br />
<br />JAN 1 0 2006
<br />
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