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<br />0-
<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 ORIGINALRECOllD-oON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S.~~~tfP!t=-WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -=-: _ o-~fu~'e" -C' ~ ~"'-
<br />
<br />DATEDFISSUANCE f~ER
<br />
<br />APR 1 3 2005 t ASSISTANrstAJ't REGtBTRAR
<br />
<br />LINCOLN, NEBRASKA 2 0 0 8 0 3 0 4 4 \~~~tr?~~~:7~~~:EiBVICES
<br />
<br />"\' - .-- ",' :;;,~ :.:_~,~~.~~~'
<br />
<br />STATE OF NEBRASKA- DEPA:~~R;lf~G~;~~tQ~A~~VI~~~ :NA:~E AND SUP:ORT 0_5-_J1AOJJt
<br />
<br />DECEDENT'S-NAME (First, Middlo, Last, Suffix) 2, SEX 3, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />~
<br />
<br />
<br />_Carl 1}€!'l}tg_~_ ___Robl~
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 50, AGE. Last Birthday 5b, UNDER' YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />Male
<br />
<br />5c, UNDER 1 DAY'
<br />HOURS MINS.
<br />
<br />A ril 2 2005
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />Petersburg, Texas
<br />
<br />69
<br />
<br />February 14, 1936
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />456-46-2323
<br />
<br />Ba, PLACE OF DEAiH
<br />1:IQSJ'1TAL
<br />
<br />o Inpatlant
<br />
<br />QIHEB; 0 Nuralng HomalLTC 0 Ho.plce Facility
<br />
<br />8b, FACILITY-NAME (If nol in.lltullon, give .treet and number)
<br />
<br />o ERIOutpati.nt
<br />
<br />~ Dacedenh Horns
<br />
<br />1030 Highland Drive
<br />
<br />D[()I\
<br />
<br />o Other (Spocify)__...__._.._
<br />
<br />~
<br />",
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Codo)
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />_ Ha~.:t;tngs__ .__ 6 I;! 9 0 1
<br />9a, RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />Adams
<br />
<br />F-
<br />gc CITY OR TOWN
<br />
<br />"'-- _H~s!ting!L'_J 6 --
<br />go A~T NO __ 9f ZIP CODE
<br />
<br />
<br />1Qb. NAME OF SPOUSE (FIrst, MIddle, Last, Suffix) If wife, give maiden name.
<br />
<br />Adams
<br />
<br />9b, COUNTY
<br />
<br />__..103Q_Highland Dd'le_
<br />lOa. MARITAL STATUS AT TIME OF DEATH Xl Married 0 Never Married
<br />
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />o Marrlad, but saparaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Peggy J. Rankin
<br />
<br />o Cremallon 0 Enlombmant
<br />
<br />
<br />SUftiX)~_~t~OTHER'S'~~A:_ ~::~iec
<br />
<br />Mlddla,
<br />
<br />Maiden Surname)
<br />
<br />fl. FATlIER'S.NAME IFirst, Middle, La.t,
<br />
<br />John__ S._....__. Nob~e
<br />13, EVER IN U.S. ARMED FORCES? Give dat.. ol..rv;c.lf y.s,
<br />(Yo., no, or unk,) No
<br />15. METHOD OF DISPOSITION
<br />Xi Burial 0 Donation
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />iSb. LICENSE NO.
<br />1/80,__
<br />__.. .-., ,',..... ,J.
<br />
<br />o Ramoval 0 Othar (Speclly)
<br />
<br />CITY I TOWN
<br />Hastings
<br />
<br />, 60. DATE IMo" Day, Yr, )
<br />April 5, 2005
<br />
<br />STATE
<br />Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (SI,..t, Ctly or Town, State)
<br />Livingston-Butler-Volland Funeral Home
<br />
<br />1225 North Elm Avenue
<br />Mastin s, Nebraska
<br />
<br />PART I. Enter the chain of Bventsudiseases, Injuries, or complicatlons--Ihat directly caused the death. DO NOT enter termInal evenls such as cardiac arrest,
<br />r..pi,alory arr..t, or ventrlcurar librillation without showing the allology. DO NOT ABBREVIATE. Enler only one cau.a on allne, Add addltlon.1Iln..If nac.ssary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to daalh
<br />
<br />IMMEDIATE CAUSE (Fln'l
<br />diS9!!!! or condition resuJtlng
<br />In d..th)
<br />
<br />._u~.1 H EP IJ II c:~~
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF;
<br />
<br />12 ft-I L-- VRr.=-
<br />
<br />onsel to death
<br />
<br />SequenUally lI~t condition!;,"
<br />any, leading 10 the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or InJuryth.t Inltl.t.d
<br />the events reSUlting In death)
<br />LA5I"
<br />
<br />(b)ME7A5'TA:nc
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />cD L-O N __.__c;lt,:,ICBF<...
<br />
<br />onsallo daath
<br />
<br />(cl
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset to daalh
<br />
<br />(dl
<br />
<br />PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to tho doalh but not re.ulting in tho undarlying cause given In PART I.
<br />
<br />'9. WAS MEDICAL EXAMiNER
<br />OR CORONER CONTACTED?
<br />o YES ~O
<br />
<br />o AccidentO Pending Inva.tlgatlon
<br />
<br />21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o DrivarlOperalor
<br />
<br />o P....ng.r
<br />
<br />o YES
<br />
<br />~
<br />
<br />20. IF FEMALE:
<br />o Nol pregnant wllhin pa'l year
<br />o Pr"gnanl altima 01 dealh
<br />o Not pregnant, but pregnant wilhin 42 days of death
<br />o NOI pregnant, but pregnant 43 day. to 1 yaar bolor. d.ath
<br />o Unknown If pregnant wllhln Ihe past yeer
<br />
<br />21a.MANNER OF DEATH
<br />u-fulural 0 Homicide
<br />
<br />o Pedestrian
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Other (Sp.cify)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH? /
<br />o YES 0 NO N A
<br />
<br />22a, DATE OF INJURY IMo" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 220. PLACE OF INJURY.AI home, farm, .tro.t, factory, office building, con.tructlon .it., .tc. (Spoclfy)
<br />
<br />m
<br />
<br />o YES 0 NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYlfOWN
<br />
<br />STIlfE
<br />
<br />ZIP CODE
<br />
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />
<br />z z~
<br />~~ ~~~
<br />
<br />'* ~ 23c.l1ME OF DEATH j ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIMEPRONOUNCEDDEAD
<br />"ii:J::::; 3:00 Pm <:>.0.<':::; m
<br />E8~~ 5~t~
<br />G.I ~ 23d. To the bast of my knowledge, dealh occurred at (he time, dale and place U LLI Z 24e. On the basis of -examination and/or Invesllgallon, in my opinion death occurred at
<br />
<br />~ ~ and due vU3i~~~~~::~:~~:::]~4~~\Y ~-Gl9t-- ~ ! ~ \-,ellmo, dato and place and duo to Iha cau..(.) .tat.d. (Signature and Till.) T
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o YES I!;r;~. 0 PROBABLY W UNKNOWN 0 YES IlkfiO' ~ot Applicable 1126a is NO 0 YES 0 NO
<br />27, NAME, Tlfl~AN6APDR~SS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSIc1AN6R"c6UNTYATTORNEY) (Typo or Print)
<br />
<br />Ashvini Sen ar M.D. North Kans Hastin s Nebraska 68901
<br />
<br />m
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />
<br />APR 11 2005
<br />
<br />\\1
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