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<br />STATE OF NEBRASKA <br /> <br />.., <br />..-. <br /> <br />W~N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEIY.:;.~f1AN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBllfJ.W.~-mp~f{;i}4ECJr OF HEAL TH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY E05r, ~4L..R.$c't!f~',. . i , <br />:-' &~Ij;;.tj.~:n_~i.. -". <br />DATE OF ISSUANCE {~_ '~~ <br />20080807 6 ~.$TANLEY S, COOPER. '. ,- .',> <br />~~~~~~~~~t::~~R <br />1Jt}(4A"f SERVlj;g5f< ... ,7;' r <br />~':~,:~f:~ ~:~:,~~(~\;,; ~~. .' <br /> <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINA~CE A'Nb SUPPO T <br />CERTIFICATE OF DEATH .. <br /> <br />AUG 2 2 2008 <br /> <br />LINCOLN, NEBRASKA <br /> <br />\ <br /> <br /> <br /> <br />1. DECEDENT'S.NAME (Fir.l, <br />Florence <br /> <br />Middl., <br />Ma <br /> <br />Last, <br />Vang <br /> <br />Suffix) <br /> <br />2. SEX <br />Female <br /> <br />Grand Island. Nebraska <br /> <br />5.. AGE.l.st Birthd.y 5b. UNDER 1 YEAR <br />(Yrs.) MOS. DAYS <br />68 <br /> <br />50. UNDER 1. DAY <br />HOURS MINS. <br /> <br />3. DATE OF DEATH (Mo.. D.y, Yr.) <br />August 17. 2008 <br /> <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br /> <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br /> <br />April 28, 1940 <br /> <br />7. SOCIAl SECURITY NUMBER <br />508-48-0981 <br /> <br />ss. PlACE OF DEATH <br /> <br />J::lQSflIi\l.: <br /> <br />o Inpatient <br /> <br />Q]jfB: 0 Nursing Hom./lTC 0 Hospioe Facility <br /> <br />FACllITY.NAME (If nol Institution, glv. stroot ond numbor) <br /> <br />o ERlOutpaMnt <br /> <br />i1 D.codent'. Hom. <br /> <br />Home: <br /> <br />2305 N. Engleman Road <br /> <br />O~ <br /> <br />o Oth.r (Sp.cify) <br /> <br />6c. CITY OR TOWN OF DEATH (Include Zip Cod.) <br /> <br />Grand Island <br /> <br />9.. RESIDENCE.STATE <br /> <br />Nebraska <br /> <br />ad. COUNTY OF DEATH <br /> <br />68803 <br />9b. COUNTY <br />Hall <br /> <br /> <br />Hall <br /> <br />9d. STREET AND NUMSER 9f. ZIP CODE <br />2305 N. Engleman Road 68803 <br />10.. MARITAl STATUS ATTIME OF DEATH ~ Married 0 Never Marrl.d lOb. NAME OF SPOUSE (Flr.t, Mlddl., last, Suffix) I!wll., give maiden name. <br /> <br />9g. INSIDE CITY liMITS <br />::lP YES 0 NO <br /> <br />o Marrl.d, but separated 0 Widowed 0 Divorc.d 0 Unknown <br /> <br />Raymond Vang <br /> <br />11. FATHER'S.NAME (First, <br /> <br />Ralph <br /> <br />Middle, <br />A. <br /> <br />le.t, sulfix) <br />Miller <br /> <br />12. MOTHER'S.NAME (First, <br />Maxine <br /> <br />Middle, <br />S. <br /> <br />Maiden Surname) <br /> <br />Olson <br /> <br />13. EVER IN U.S. ARMED FORCES? Give dotos of service il y... l4a.INFORMANT.NAME <br /> <br />o Entombment <br />o Oth.r (Sp.city) <br /> <br />l6d. CEMETERY, CREMATORY OR OTHER LOCATION <br /> <br />CITY I TOWN <br /> <br />l4b. RElATIONSHIP TO DECEDENT <br /> <br />Husband <br /> <br />l6c. DATE (Mo.. D.y, Yr. ) <br />Au ust 19, 2008 <br />STATE <br /> <br />No <br /> <br />o Donation <br /> <br />16a. EMBALMER.SIGNATURE <br />Not Embalmed <br /> <br />Raymond Vang <br />16b. LICENSE NO. <br />N/A <br /> <br />Central Nebraska Cremation Service <br /> <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Stra.t, City Or Town, St.te) <br /> <br />Apfel Funeral Home, <br /> <br />PART l. Enter the chain of evenlfl--dlseases, InJurIes, Or complicationSnthat directly caused the death. DO NOT Bnler terminal events such as'cardlac arrest! <br />re.plr.tory .rrest, Or ventricul.r fibrill.tion without .howlng th. .tlology. DO NOT ABBREVIATE. Enl.r only on. caus. on a line. Add .ddltion.llines if nece.sary. <br />IMMEDIATE CAUSE: <br /> <br />(a) IN.....Q\U t2 v~(,.--.() '~-" <br />DUETO, OR AS A CONSEQUE~CE OF: - J <br /> <br />on..t to daath <br /> <br />IMMEOIATE CAUSe (Final <br />dl..... or condition ","ulllng <br />In_) <br /> <br />o-[rL/+- <br /> <br />! onset to death <br /> <br />Sequonti.lly 1I0t condltionl, II <br />.ny, loading to the o.u..lllted <br />on IIn... <br />Enter !he UNDERLYING CAUSE <br />(dl..... or Injury thlt Inltllted <br />the e.ents ...ulUng In death) <br />lASr <br /> <br />\ <br />(b) \.\. ,~...., c---L <br /> <br />DUE TO, OR AS A CONSEQUENCE OF: <br /> <br />.5 '.....r-ctl ~ <br /> <br />ons.t to d.ath <br /> <br />(c) <br />DUE TO, OR AS A CONSEOUENCE OF: <br /> <br />onsat to de.th <br /> <br />(d) <br /> <br />16. PART II. OTHER SIGNIFICANT CONDITIONS.CondIUons oontributing 10 ths deeth but nol r.sulUng in tha undorlying ceuse given in PART I. <br /> <br />1 g. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />DYES c;rN().. <br /> <br />20. IF FEMALE: <br />~r.gnant within past yoer <br />o pr.gnantat Umo of de.th <br />o Not pregn.nt, but pr.gnanl within 42 days of death <br />o Not pragnant, but pr.gnant 43 days to 1 year betor. d.ath <br />l:J Unknown it pregnant within the past year <br /> <br />21.. MANNER OF DEATH <br />~~"I 0 Homicide <br /> <br />o AccidentO Pending InvesUgaUon <br />o Sulcid. 0 Could not ba datermined <br /> <br />2td. WERE AUTOPSY FINDINGS AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? <br />Dyes O.NO <br />2k ptAcl;--OFiNJURY.At hom., farm, .tra.t, lootory, oftioe building, construction site, elc. (Spaclfy) <br /> <br />21b.IFTRANSPORTATION INJURY <br />o Drlvar/Oper.tor <br /> <br />o P....ng.r <br /> <br />o P.d..trlan <br /> <br />o Olher (Specify) <br /> <br />21C. WAS AN AUTOPSY PERFORMED? <br /> <br />DYES <br /> <br />~ <br /> <br />DYES 0 NO <br /> <br /> <br />220. DATE OF INJURY (Mo.. Da~ Yr.) <br /> <br />22d.INJURY AT WORK' <br /> <br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO. <br /> <br />CITYITOWN <br /> <br />ST!(fE <br /> <br />ZIP CODE <br /> <br />24a. DATE SIGNED (Mo., D.y, Yr.) <br /> <br />24b. TIME OF DEATH <br /> <br />m <br /> <br />1i~~ <br />-'" <br />~g!O <br />iiif5::; <br />~~t~ <br />"I.U~ <br />llZ=> <br />~5~ <br />00 <br /> <br />m <br /> <br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD <br />m <br /> <br />248. On the basis of examination and/or investIgation, In my opinion death occurred at <br />th.tim., d.te and plaoe and due to the c.u.e(s) .t.tsd. (Signature and Tilla) ... <br /> <br />25. DID TOBACCO USE CONl:RIBUTETOTHEDEATH? 26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED' <br />-------0 ../" A / .L1. .-. ~ <br />DYES Q.1(o . PROBASLY 0 UNKNOWN 0 YES (J"'"No I '''''..Not Applioable if 26. Is NO 0 YES L.:rN0 <br />---;'-7:-N"AME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)- ....-- 68803 <br />Kenneth L. Vettel M.D. 2116 West Faidley Ave., Suite #400, Grand Island, NE <br /> <br />26a. REGISTRAR'S SIGNATURE <br /> <br /> <br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br /> <br />AUG 2 1 2008 <br />