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<br />~.".
<br />
<br />
<br />STATE OF NEBRASKA .
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF TH
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE C~p~E~;:~:~=f:;~~1 ~~~.~UM.'. .' 'AN.. S. ERV,./CES
<br />THE NEBRASKA HEALTH AND HUMAN SERVIC .~u"ONF1Lg WITH'
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDff.S SYSTEM, VITAL STAT/~~~,~~.~~,!~~~ !~.
<br />
<br />DATE OF ISSUANCE M,~~.j~>>.',..
<br />JUN 0 r:: 2008 )'~~:t?"iJ;;;i-:~~, -.,., ~; /.
<br />~ U ~ ~ ~ : ~'~""',!'~.!I .7:" JO-
<br />LINCOLN N 4). 'fA ~. .'...y"
<br />, EBRASKA H~ ..~.... fj,J~~>,.
<br />
<br />200807308 · >>:;.:\:~g?}'..c.-
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES "'~A~ ANO'~X c"':::"'J";".--. 6" --5" '5
<br />CERTIFICATE OF DEATH '. '"!, ,."J..tQ."--6.-.:. - - 3
<br />I.DECEDENT'HlAME (First, Middle, Laot, Suffi') 2. SEX '3. DATE OF DEATH (Mo.. Day, Yr.)
<br />Sheldon J. Dethloff Male June 17, 2008
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />sa. AGE.Lo.t Bir1hday 5b. UNDER I YEAR
<br />(Yro.) MOS. DAYS
<br />78
<br />
<br />5c. UNDER I DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (MO., Dey, Yr.)
<br />
<br />Harvard, Nebraska
<br />
<br />October 31, 1929
<br />
<br />aa. PLACE OF DEATH
<br />~:
<br />
<br />. Inpatient
<br />
<br />QD:JEB: 0 Nursing HomolLTC 0 Hospice Fsellity
<br />
<br />-;~~'
<br />.' ,
<br />
<br />a'decldenr;fiOm.
<br />
<br />Cl ERlDutpatlent
<br />
<br />Saint Francis Medical Center
<br />
<br />Se. CITY OR TOWN OF DEATH (lnelude Zip Code)
<br />Grand Island, 68803
<br />
<br />9a. RESlDENCE.STATE
<br />Nebraska
<br />
<br />Cl CO\ Cl Other (Specify)
<br />
<br />Sd. COUNTY OF DEATH
<br />Ball
<br />
<br />!lb. COUNTY
<br />Hall
<br />
<br />
<br />Sf. ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />. YES Cl NO
<br />
<br />St
<br />
<br />lXM.rried CI Never Married 10b. NAME OF SPOUSE (First, Middle, La.t, Sulfi.) If wile, give maiden name.
<br />ClDlvorced OUnknown Vivian I Stuart
<br />
<br />1 I. FATHER'S.NAME (First,
<br />Reinhold
<br />
<br />Middle,
<br />
<br />Last, Sum.)
<br />Dethloff
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Miriam
<br />
<br />Middle,
<br />
<br />Meldan surn.me)
<br />Nowka
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dste. of aeNlcelf ye.. 14a.INFORMANT.NAME
<br />(Yas, no, 01 unk.) No Vivian I Dethloff
<br />16. METHOD OF DISPOSITION 16s.EMBALMER.SIGNATURE lab. LICENSE NO.
<br />o Burial o Donation Not Embalmed
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />lae. DATE (Mo., Day, Yr.)
<br />Jun 17, 2008
<br />
<br />lXCremation 0 Enlombmenl
<br />
<br />lad. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY (TOWN
<br />
<br />STATE
<br />
<br />o Removal 001her(Speclfy) Central Nebr. Cremation Servic Gibbon
<br />
<br />NE
<br />
<br />17a. FUNERAL HOME NAME ANO MAILING ADDRESS (Street City or Town, Sllte)
<br />curran FuneX'a~. ChapeJl. 3OOi. ~tl;l.,~'f~.~
<br />
<br />PART I. Enter the chain o'eventa-.diseaaes, inJuries, or compllc.tions..thst dlreclly caused the Uesth. DO NOT entar 'ermlnel ovanlS such ss cardlsc .rre.l,
<br />respiratory arresl, or ventricular IIbrlllallon without.howlng tha atiology. 00 NOT ABBREVIATE. Enlal onlY one eau.e on a line. Add additional line. If n.c....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />on.et to de.th
<br />
<br />IMMEDIATE CAUSE (Flno'
<br />dl_" or condition rosuIting
<br />in deeth)
<br />
<br />(a) '-~jJr/I.A'ftJ(l y /A/~uA[
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />/z-f)1r!5
<br />
<br />I onsellodeath
<br />
<br />Soquentlally lI.t condlllons,lf
<br />sny, Ie.ding to the cauaalletsd
<br />on line a.
<br />Enterlhe UNDERLYING CAUSE
<br />(UI..... or Injury thsllnlllelo<l
<br />th& ""enll lUulting In <*dII)
<br />LAST
<br />
<br />(b) C- 0 I! f)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />
<br />I (j "I.AJ
<br />
<br />on.e' to de.lh
<br />
<br />(c)
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />_.~
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.ConUilions contributing to the d.eth but not ra.uitlng In 'lie underlying csuse given In PART I.
<br />
<br />(d)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES II: NO
<br />
<br />&vJLl- I Uhll17o..J
<br />
<br />21.. MANNER OF DEATH
<br />RN.tural CI Homicide
<br />
<br />o Accident Cl PenUlng Invesllg.llon
<br />
<br />o Suieida Cl Could not ba Uetarmlned
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />IJ Driver/Operator
<br />
<br />20. IF FEMALE:
<br />
<br />o Nol pregnanl within pssl ye..
<br />CI Pregnanlel lima of death
<br />Cl NOI pregn.nt, but pregnant within 42 day. of death
<br />Cl Not pregnanl, bul pregnant 43 day. to t yaar balor. death
<br />o Unknown if preg(,ant wilnin the past yMt
<br />
<br />CI Ps.senger
<br />Cl Pede.trian
<br />IJ Other (Specify)
<br />
<br />o YES
<br />
<br />MNO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22a. DATE OF INJURY (111.0" Day, Yr.)
<br />
<br />I
<br />22b. TIME OF INJURY
<br />
<br />22e. PLACE OF lNJUIIY.,i,i hCme,ilmi, at_t, _ry, 0_ blIildi1g, conatrUCtion ~I.l" etc. (Specify)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES Cl NO
<br />
<br />2~1. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CrrYlTOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />li~i
<br />
<br />23b. DATE SIGNED (Mo., Day, YrJ... 23C.TIME OF DEATH A l~ ~ 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />_ .01 :C)1mn ~~~ m
<br />
<br />23d. To the best 01 my knowledge, dealh occurred al the lime, dale and place iiI !i 0 24e. On tne be.is ole..mlnallon and/or ;nva.llgatlon, In my opinion dealh occurred at
<br />end due I ause(s,) sl d. (~natjl'\rrTill.) '" ~ 11 ~ 5 Ihetlme, date and plaCe sndduetothecau.e(s) .t.ted. (Sl9I1atura and Tllle)Yf
<br />
<br />(t (JJt- ~/ ~8~
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTME DEATM? 2a.. MAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />24s. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />
<br />2all. WAS CONSENT GRANTED?
<br />
<br />~. CI YES NO CI PROBABLY 0 UNKNOWN Cl YES lX NO
<br />27. NAME, TITLE NO ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Prinl)
<br />David R. Colan NO 729 N. Custer AV, Grand lliIl.and, NE 68803
<br />
<br />No! Appllcsble if 26a I. NO CI YES . NO
<br />
<br />ns. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />JUN 2 3 2008
<br />
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