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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANJH!1.!MAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN~Ct::iJ!W'~BLE"Wi'rH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAJj$T!PS-Siil'ii'IOf!:WNICI:fIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS", "'--=-'~J! ," ,c:: j:ii~~ .
<br />
<br />OATEOF/SSUANCE ~~~If
<br />
<br />JAN .2 5 2007 j J$S~S.TANT STArE RE,Gt$TfJAR
<br />LINCOLN, NEBRASKA 2 0 0 8 0 215 t H'~T~ND,HJlMAN-SE~'ftCES
<br />
<br />',-J'~
<br />
<br />"
<br />
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<br />-.- ,-,,-,,--,-,.,~'~:".~.'.---
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<br />........-. .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC, E, ,8 FINANCE AND SUPP05 R
<br />CERTIFICATE OF DEAT_Ii...n ' "- '.
<br />
<br />34055
<br />
<br />DECEDENT'S-NAME (FlrSl,.
<br />Richard
<br />
<br />Middle,
<br />Russell
<br />
<br />Last.
<br />Rehder
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo" Dey, Yr.)
<br />__ _P_t:J9_~p1ber 21, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.La,t Birthday 5b. UNDER 1 YEAR
<br />(Yrs) 63_M_O~~eAYS
<br />
<br />llla. PLACE OF DEATH
<br />1::iQ.S!:JIAI.: liO tnpatient
<br />
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" Day, Yr.)
<br />HOURS MINS.
<br />
<br />Grand Island, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBI;R
<br />505-54-3776
<br />
<br />November 2, 1943
<br />
<br />QIliER: 0 Nursing Home/LTC U Hospice Facility
<br />
<br />6b. FACILITY. NAME (If not Institution, give Slreet end number)
<br />
<br />o ER/Oulpalienl
<br />
<br />o Decedent's Home
<br />
<br />'"
<br />.~.,
<br />
<br />...Bl"'yanLQI:I Medical Center West
<br />8e. CITY OR TOWN OF DI;ATH (InClude Zip Coda)
<br />
<br />o [l)O, 0 Olher (Spoolly)
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />
<br />Lincoln 68502
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />9b. COUNTY
<br />
<br />1~_~~ Or:~I.'J:J~e Road _
<br />lOa. MARITAL STATUS ATTIME OF DEATH Oo:Marrled 0 Never Married lOb. NAME OF SPOUSE (Flrsl, Middle, LaSl, Suffix) If wile, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />o Divorced 0 Un~nown
<br />
<br />Middle,
<br />
<br />La,l,
<br />
<br />Le~~:Ilyn Schroeder
<br />Suffix) 12. MOTHER'S-NAME (FlrSl,
<br />Edna
<br />
<br />Middle, Maiden Surname)
<br />Hennin s
<br />
<br />Rehder
<br />
<br />U Cremallon U I;nlombmonl
<br />
<br />16d. CEMETERY, CREMATOR
<br />
<br />CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />16e. DATE (Mo" Doy, Yr. )
<br />
<br />December 26, 2006
<br />
<br />STATE
<br />
<br />(Yos, no, 01 unk.)
<br />
<br />No
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />16a. EMBALMER-SIGNATURE
<br />
<br />16b. LICENSE NO.
<br />
<br />JO Burial
<br />
<br />o Donation
<br />
<br />1362
<br />
<br />o Romoval 0 Olher (Spocify)
<br />
<br />Cemete~~
<br />Park Cremate! T
<br />
<br />Grand Island
<br />
<br />Westlawn Memorial
<br />.--- --... ,..,.",,~,~-----~.
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, Slale)
<br />Livingston-Sondcrmann Funeral Home,
<br />
<br />18. PART I. Enter the chAin of evenlsndiseasas, Injuries, or compllcatlonsnlhat dlrsctly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />re'plralory arrest, or venlrlcular fibrillation withoul showing the eitology. DO NOT ABBREVIATE. Enler only one cause on a line. Add additional line. if necessary.
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />dIS!!!!!! or condillon r!!$ultlng
<br />In death)
<br />
<br />(a)
<br />
<br />MfrSSlvf
<br />
<br />I NT~1t ClUH11l'rL
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />
<br />HEMOKK.HIrGt E___~_m( G ~)
<br />
<br />I on.ol 10 doalh
<br />I
<br />I
<br />I
<br />I onsel\o dealh
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequl!lntlally list condlllons, If
<br />any, leading to the eeu.ell>led
<br />on line B.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury thallnltialed
<br />the events re.uitlng In death)
<br />LMr
<br />
<br />(b)
<br />DUI; TO, OR AS A CONSI;QUI;NCI; OF:
<br />
<br />(e)
<br />DUI; TO, OR AS A CONSI;QUENCE OF:
<br />
<br />onsel 10 death
<br />
<br />(d)
<br />
<br />PART II. OTHI;R SIGNIFICANT CONDITIONS.Condition. conlributing to Ihe death but nol resuiting In Ihe underlying cause given In PART I.
<br />
<br />pq..YO~>~ ~--pn'/l~ j ~
<br />
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH.
<br />~alural 0 Homicide
<br />
<br />o AccidentD Pending lnvBsUgation
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Nol pregnant within past year
<br />o Pregnant al lime 01 dealh
<br />o NOI pregnant. bUI pregnonl wilhin 42 day. of death
<br />o NOI pregnanl, bUI pregnant 43 days to 1 year bel ore dealh
<br />o Unknown If pregnant wllhln the past year
<br />
<br />o Passenger
<br />U Pedestrian
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />U Olhor (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAiLABLE' TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />U YI;S U NO
<br />
<br />
<br />22c. PLACE OF INJURY.At homo, farm, .Ireet, faclory, office building, eonatrueUon aUe, ale. (Specify)
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY STREET & NUMBI;R, APT NO.
<br />
<br />CrTYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />s~ H.,P
<br />
<br />,.,a
<br />~~~
<br />n~
<br />a.D.. l( ~
<br />e.'" ~ is
<br />8ffiz
<br />..z::>
<br />.cOO
<br />~a:U
<br />85
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />022.>" m
<br />
<br />24<. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIMI; PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the limo, dale and place and due 10 Ihe eause(s) slaled. (Signature and Tille) l'
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSI;NT GRANTED?
<br />
<br />27.~~~~(r~~~~~~t~~~FIER~P~~s~gl~~~ORr~;~~~;ct~o;ct~~5~~~; or prink tY AN z~p~ca:e i1-:~S~ L: YESN ~O
<br />
<br />28b. DATE FILEDII1E'eIS!A'8(~O'rr~r.)
<br />
<br />p C ~
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