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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
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<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 />
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<br />
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<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
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