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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH Al'igJ:IfJMAN.s"'EFfVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAl,.~9.qf!l?>PtV}CE'VfITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA1J,I'hf?~~J;c.J:IG,!J..~Hlt:H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. :' '...... ~ ,'-;' ~\\ ~,l7f~ .~~.{ .:
<br />DATE OF ISSUANCE ti--: . ~ .f.&1C'I'~ '.,:;' 'j
<br />APR Z 9 ZOO8 .: ... ~ -"~.,;;;~. .~
<br />~~AN tiIltliERlsTR14Eti?
<br />LINCOLN, NEBRASKA Ji(4lf!.tMND HUMAN SERVIt;EiS ~'
<br />20080586t:::: \$ c?\ ;',. ,"~::-i ,~
<br />
<br />.. '<It V t.IIf....;;-,. -.,/ ~...t ---
<br />~,. ~'" '.' /:JIi~i j .... ,....... \"';'''"."..Jl,..)
<br />
<br />C. '<' ,fl" .... ~.: :,':., - ~'\ ..,....
<br />, '...J ')\) "'"
<br />STATE OF NEBRASKA ~ DEPARTMENT OF HEALTH AND HUMAN SERVICES f'lrt~~1" .4NP'I>uPf'~ 2 4 2 9 8
<br />CERTIFICATE OF DEATH " .. \. . , ,,_ ,,~1j 0
<br />2.8'6- -
<br />Male
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Rodney
<br />
<br />Mlddl.,
<br />Rodger
<br />
<br />La.t,
<br />Rathman
<br />
<br />Suffix)
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 20, 2008
<br />
<br />
<br />4. ClfY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.La.t Birthday Sb. UNDER 1 YEAR
<br />(Yro.) MOS. DAYS
<br />81
<br />
<br />Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />HOURS MINS.
<br />
<br />Cairo, Nebraska
<br />
<br />September 11, 1926
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-48-6158
<br />
<br />8a. PLACE OF DEATH
<br />I!QSE!IAI: a Inpatient
<br />
<br />CllJm lSl Nursing Home/LTC a Ho.pice Facility
<br />
<br />8b. FAClciTY.NAME (If not Institution, glvo streBt and number)
<br />
<br />Q Ef1l0utpatient
<br />
<br />Q Decedent'. Hom.
<br />
<br />Western Hall County Good Samaritan
<br />
<br />Q ID. Q OthBr (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />8c. CITY OR TOWN OF DEATH (Includ.Zip COdB)
<br />Wood River
<br />ga. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />780 North 130th Rd.
<br />
<br />68883
<br />
<br />
<br />9b. COUNTY
<br />
<br />Hall
<br />
<br />91. ZIP CODE
<br />68883
<br />
<br />9g. INSIDE CITY LIMITS
<br />Q YES Xl NO
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~arrlBd Q N.v.r Marri.d lOb. NAME OF SPOUSE (First, Mlddl., Last, Suffix) IIwifB, glv. mald.n n.m..
<br />
<br />Q Marrl.d, bUl..parat.d Q Widow.d Q Dlvorc.d IJ Unknown Phy llis Harders
<br />
<br />11. FATHER'S-NAME (First,
<br />Edward
<br />
<br />Mlddl.,
<br />
<br />La.t,
<br />Rathman
<br />
<br />SuffiX)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Dora
<br />
<br />Mlddl.,
<br />
<br />Maid.n Surn.m.)
<br />Stoltenberg
<br />
<br />13. EVER IN U.S. ARMED FORCES7 Glv. dot.. ol.orvlc.1I Y.'. 14a.INFORMANT.NAME
<br />(Y",no,orunk.) No Phyllis Rathman
<br />15. METHOD OF DISPOSITION
<br />Q(eurlal IJ Donation
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />Cl Cr. motion IJ Entombment
<br />
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />16b. LICENSE NO.
<br />JaB
<br />
<br />16c. DATE (Mo.. Day, Yr. )
<br />April 23, 2008
<br />
<br />IJ R.moval IJ Oth.r (Sp.cify)
<br />
<br />Cairo, Nebraska
<br />
<br />Berwick Cemetery,
<br />
<br />17e. FVNERAL HOME NAME AND MAILING ADDRESS (Str..t, City or Town, Stat.)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />PART I. Ent.r the choln of .v.nts..dls....., injuries, or complications..th., dlr.ctly c.us.d the d.alh. DO NOT .nt.r t.rmin.l.v.nt. .uc~ .s c.rdlac arr..t,
<br />re.piratory a"o.t, or v.ntricul.r IIbrillatlon wifhout showing the .tiology. DO NOT ABBREVIATE. Enter only on. cau.. on .Iina. Add .ddition.lllne. if n.ces..ry.
<br />
<br />IMMEDIATE CAUSE: ~
<br />
<br />(a) ~~.:J ~'fe. Y A.. (t ~ ,,\ ~ \ tJ~'(f\i E..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..t to de.th
<br />
<br />.) \0
<br />
<br />f\J
<br />
<br />onset to d.ath
<br />
<br />Sequenti.lIy lIat conditions, if (b)
<br />sny,IOBdlngtothe..usellstod DUE TO, OR AS A CONSEQUENCE OF:
<br />on linea,
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or Injury t~a1lnltlst.d (c)
<br />theOVlHltB rosuhlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LJSJ'
<br />
<br />onset to death
<br />
<br />ons.t to d..t~
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the d..th but not r.sulting In the und.rlying cau.. givon in PART I.
<br />
<br />~~VW\:L ~-C' \-c 'i<)'~.:K 6\l'-~~~\ c.J~ \ i\~l\J f)
<br />
<br />20. IF FEMALE: \.l "" 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY
<br />IJ Not pr.gn.nt within past y.ar .a;.Natur.i Cl Homicid. IJ Drlv.r/Op.r.tor
<br />IJ pr.gn.nt at tlm. of death Q Accid.ntlJ P.nding Investig.tion IJ P....ng.r
<br />Cl Not pregnant, but pr.gnant within 42 days of d.at~ IJ P.d..trl.n
<br />IJ Suicld. a Could nol b. determln.d
<br />Cl Not pr.gnant, but pr.gn.nt 43 days to 1 YB.r before d..th
<br />a Unknown II prBgnant within th. pa.t y.ar
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />IJ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />IJ YES r;t.NO
<br />
<br />Q Ot~.r (Sp.clfy)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAiLABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />IJ YES IJ NO
<br />
<br />22b. TtME OF INJURY
<br />
<br />22c. PLACE OF INJURY.AI hom., farm, otr..t, factory, offic. building, construction .It., .,c. (Sp.cify)
<br />
<br />22a. DATE OF INJURY (MO.\D.y, Yr.)
<br />\>Jf>\
<br />
<br />22d.INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />m
<br />
<br />IJ YES Cl NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />~
<br />
<br />~~~
<br />l~~~
<br />~,~~
<br />"Ill:::>
<br />.DiSo
<br />~~(,)
<br />o~
<br />1,10
<br />
<br />24.. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or investigation. in my opinion death occurred at
<br />t~o time, d.t. and ploc. .nd due to the c.u..(.) .Iat.d. (Slgnatur. and Titl. ) ,.
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />_._~g NO IJ PROBABLY li(UNKNOWN Q YES ~O Not Applic.bl. if 26. is NO IJ YES 0
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Steve Husen M.D. 2116 W_, Faidley Av '. Grand Island, NE 68803
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR IMc., D.y, Yr.)
<br />
<br />APR J 4 2008
<br />
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