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<br />WHEN mls COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANQHUMAN SERVICES <br />SYS1EM, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAtcIiECORD-ONEILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAmTlCs:sEC'1IOitWHICH IS <br /> <br />:::;::~:::::~TORY FOR VITAL RECORDS. F-' ...-- - -: if)r:;;,fv <br /> <br />MAR 5 ?001 2007056 ~Aia.iYS",CoQpER <br />L 0 4_AMlstANt STAtE'll;@ls}iRAR <br />LINCOLN, NEBRASKA HEAL TH AN()flCJM~ S~~'1!.c.J$'S'gTEM <br />-." -'-'=':-_'...-.i" <br />STATE OF NEBRASKA~ DEPARTMENT OF REALTII AND HI.JMAHSElvfCES,FlN"ANa:~ SUPPORT <br /> <br />CERTI~~S;~~~~EATH-"' ____,-to--- 01 02098 <br /> <br />I DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LASl <br /> <br />2 SEX <br /> <br />:3. DATE OF DEA lH I^'!.Onth. Day. Yearl <br /> <br />Cad <br /> <br />Fritz <br /> <br />Pape <br /> <br />Male <br /> <br />February 21, 2001 <br /> <br />Geossersen, Germany <br />SOCIAL SECURTlY NUMBER <br /> <br />Sa AGE - Last Birthday <br />(Yrs I <br /> <br />87 <br /> <br />UNDER 1 YEAR <br />5b MOS. I DAYS <br />I <br /> <br />UNDER 1 DAY <br />5c. HOURS' MINS. <br /> <br /> <br />6. DATE OF BIRTH fMoorfl. Day. Year) <br /> <br />4 CITY AND STATE OF BIRTH (If not in U.SA., namecountryJ <br /> <br />December 15, 1913 <br /> <br />~ 7. <br />IJ <br />.1 <br />') B" <br />.l <br />'.1 <br />"1 <br /> <br />FACILITY - Name <br /> <br />(II not In$tiluli(Jn, give $lr981 ana !lumber) <br /> <br />6a. PLACE OF DEATH <br /> HOSPIT AL. D Inpalient Q!~".~ [Xl NurSing Home <br /> D ER OutPatieot D FleSldenCe <br /> 0 DOA 0 Other (SpeclfYI <br /> <br />507-48-4881 <br /> <br />Lakeview Nursing/Rehab Center <br /> <br />10. RAe!;. - (e,g., While. Ellack. Am~:me;an Indian. <br />otCIISpoc,1y1 Whi te <br /> <br />11. ANCESTRY lo.g <br />ISpe"lyl Amer ican <br /> <br /> <br />8d INSIOE. CITY LlMllS <br /> <br />COUNTY OF DEATH <br /> <br />Be CITY. TOWN OR LOCATION OF DEATH <br /> <br />Grand Island <br /> <br />Hall <br /> <br />Nebraska <br /> <br /> <br />Hwy #34 68801 <br /> <br />Yes [] No D <br /> <br />9a RESIDENCE - ST A TE <br /> <br />COUNTY <br /> <br />STREET AND NuMBER Ilncludlng Zip C_I <br /> <br />Se. INSIDE CITY LIMITS <br /> <br />13 NAME OF SPOUSE (If wife. give maiden nfimBI <br /> <br />MIDDLE <br /> <br />Agriculture <br />LAST 17 MOTHER <br /> <br />Adeline Long <br /> <br />15. E.OUCATION {SpeCify only hlgM!lt grade tomplel8clJ <br />Elemen~r2or SeeOnclafy (0-121 College 11.4 Of 5+1 <br /> <br />q <br /> <br />14a USUAl,. OCCUPA1ION {Give kmd of wofk don8 during most <br /> <br />of workmF~~~~~'f6dJ <br /> <br />t4b <br /> <br />.... <br />.j 16 FATHER" NAME <br /> <br />.. <br />.. <br />'II 1 B WAS DECEASEO EvER IN U.S. ARMED FORCES' <br />(Yes. 1'10. Of unk.l (II yes. give war and dstas of s,ervices,) <br />No <br /> <br />FIRST <br /> <br />MIDDlE <br /> <br />MAIDEN SuRNAME <br /> <br />Fred <br /> <br /> <br />Anna <br /> <br />Miller <br /> <br />1 Bb INFORMANT <br /> <br />MAiliNG ADDR1:SS <br /> <br />Joyce Rasmussen <br />ISTR"ET OR R.F D NO CITY OR TOWN. STA TE. ZIPI <br /> <br />515 <br /> <br />Grand Island, NE <br /> <br />68801 <br /> <br /> <br />" .,; 13 <( <br />/.1;;1~ c <br /> <br />21 a METHOD OF DISPOSITION <br /> <br />21b. OAT I;: <br /> <br />~10 CEM1:TERY OR CREMATORY NAME <br /> <br />IZJ Burial <br /> <br />D Re"'o,OI i Feb. 24 I 2001 Cedar View Cemeter <br />fd CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br /> <br />D DocOl'OO Doni han, Nebraska <br /> <br />Apfel-Sutler-Geddes <br />22b FUNERAL HOME ADDRESS ISTREET OR RF.D. NO CITY OR TOWN. STATE. ZIPI <br /> <br />D Cremahon <br /> <br />1123 West Second, <br /> <br />Grand Island, Nebraska <br /> <br />68801 <br /> <br />.. <br />,~ <br />-.I <br />. <br />:J <br />.. <br /> <br />23 1M MEDIA TE CAUSE <br />PART <br />I lal MYOCARDIAL INFARCT <br />DUE TO. OR AS A CONSEOUENCE OF <br /> <br />rENTER ONl,.Y ONE CAuSE PER LINE FOR ial. (1:>). AND (ell <br /> <br />InlerV;jl1 between ons,el ~nd dealt. <br /> <br />o <br /> <br />Il'lterval between onset aM oeM' <br /> <br />lei ATHEROSCLEROSIS <br />DUE TO. OR AS A CONSEOU"NCE OF. <br /> <br />~6a <br />0 Accident 0 Undetermmed <br />0 Suicide 0 paneling <br />0 Homie;ide Investigation <br /> <br />26" DATE OF INJURY (Mo.Oay. y,.) 260 HOUR OF INJURY <br /> <br /> <br />40 .Y13-S <br />I Interval between onset and ditalF <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br /> <br />lei <br />OTHER SIGNIFICANT CONDITIONS. Conditions contributing 10 ,he dealh but nol related <br />PART <br />II <br /> <br />COPD <br /> <br />260. INJURY AT WORK <br />Yes 0 No D <br />273. OATE OF DEATH (Mo.. Day. Yr'.J <br /> <br />26g. LOCATION <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />2Ba. DATE SIGNED (Mo..Oay. YI./ <br /> <br />28b. TIME OF DEATH <br /> <br />02/21/01 <br /> <br />~7b DATE SIGNED (Mo.. O8y. Y,.j <br /> <br />31 <br /> <br /> <br />02/21/01 <br /> <br />5 <br /> <br />" ~ <br />=--<( L....J <br />D~~ <br />ht::~ <br />8~~~ <br />E~3 <br />>~ Ii' 0 <br />o ~ <br /> <br />M <br /> <br />~i5" <br />~! I~ ~ <br />~ iE:f <br />~ ~o <br />- q~ <br />.. .~ !I <br />II <br />J <br /> <br />TIME OF DEATH <br /> <br />2Bc. PRONOUNCED DEAD (Mo.. Ooy, YI./ <br /> <br />~8d. PRONOuNCED DEAD (Hou" <br /> <br />AM <br /> <br />M <br /> <br />IInd due 10 the <br /> <br />26e. On the basis of ell:amina11on and 'Of' inve$ligatron. in my opinion death QCCI,II'l'ed at <br />the time. dale and place and due 10 lhe (:~u5ef51 5lated, <br /> <br />NO <br /> <br />JO." WAS CONSENT GRANTED' <br />DYES <br /> <br />:D NO <br /> <br />29 <br /> <br />Larry Hansen <br />n. R"GISTRAR <br /> <br />M.D. <br /> <br />3016 W, <br /> <br />nd Island, NE. <br /> <br />68803 <br /> <br />Jle DATE FILED BY REGISTRAR (Ma.. o.v. v,.j <br /> <br />MAR <br /> <br />2 2001 <br />