|
<br />Q
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT7Jf/HEAL T~..QNa.~N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4$t{A. Qff(f.'{?;P'1f:!!V1r 'fJ.F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY.F ;tD0Jt:'fI. ~V:'~~~p~~~"""'/"'~: l.i, .
<br />
<br />DATE OF ISSUANCE ~'~_ ... r"' I
<br />2 2 2 :-Si'ANLEY s. cd6l>ER ...... ". c' ~
<br />SEP 2 4: Z008 2 0 0 9 0 0 :..:AS? iSTAllTTilAl(: IfEGI$r~F{,
<br />.'pEPART~rIFoFNEi4kTH.:A~,;
<br />'.HHM11N SERVICES .' ;".' "
<br />LINCOLN, NEBRASKA ~"
<br />': :;';. ", /"'''", i'- '. ,,-
<br />f 'jf,~'.~8R' c...\'. ~. ~ .
<br />i \ "S> """!:", '..~
<br />t "UIY" -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A~~ ~~~5flkI8' ',.:_ -
<br />~ERTIFICATE OF DEATH ' "'0
<br />
<br />1. DECEDENT'S.NAME (First,
<br />
<br />Garry
<br />
<br />Middle,
<br />Paul
<br />
<br />Last.
<br />Rodewald
<br />
<br />,. Suffix)
<br />
<br />3, DATE OF DEATH (Mo., Doy, Yr,)
<br />September 16, 2008
<br />
<br />6, DATE OF BIRTH (Mo., Doy, Yr.)
<br />
<br />Merrick County, Nebraska
<br />
<br />5a. AGE.last Blrthdoy
<br />(Yrs,) 69
<br />
<br />
<br />2. SEX
<br />Male
<br />
<br />
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />October 24, 1938
<br />
<br />7. SOCIA~ SECURITY NUMBER Sa. P~CE OF DEATH
<br />- ~~l)-46-0_993 . - =I!:iQWIAl..
<br />
<br />8b FACILITY-NAME (If not InstitutIon, gIve street and number)
<br />
<br />St. Francis Medical Center
<br />
<br />Xllnpalient
<br />
<br />QIWj;
<br />
<br />o Nursing Home/LTC Q HospicB FacIlity
<br />
<br />Q ER/Outpatient
<br />
<br />Q Decedent's Home
<br />
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68803
<br />Lou~ll
<br />
<br />Q OCV\ Q OIMr (Specify)
<br />
<br />~IUNTY OF DEATH
<br />Hall
<br />
<br />-l=TOWN
<br />Grand Island
<br />
<br />l~~~O;~3
<br />
<br />lOb, NAME OF SPOUSE IFlrst, Middle, ~asl, Sullix) If wllo, gluo maiden name.
<br />
<br />9g, INSID~ CITY LIMITS
<br />:&l YES Q NO
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />1811 Grand Island Ave.
<br />lOa, MARITA~ STATUS ATTIME OF DEATH '* Merried 0 Noue' Married
<br />
<br />Q Married. but separated Q Widowod Q Divorcod Q Unknown
<br />
<br />11, FATHER'S.NAME (First,
<br />
<br />Glenn
<br />
<br />Middle,
<br />L.
<br />
<br />~ast. Sullix)
<br />
<br />Rodewald
<br />
<br />Sandra Boyll
<br />
<br />12. MOTHER'S.NAME (First.
<br />Lucille
<br />
<br />Middle,
<br />
<br />M.
<br />
<br />Malden Surname)
<br />
<br />McClure
<br />
<br />14b, RE~ATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />13. EVER IN U,S, ARMED FORCES? Give dota. of sorvlcell yes. 14e,INFORMANT.NAME
<br />1);;~~Vorun~-1-1957 1-31-1961 Sandra Rodewald
<br />1;,METHODOFDISPOSITION -~ .SIGNATU "~6~,L1CENSENO,
<br />O[Surlol Q DonOllon I 4 -------L / z yo
<br />Q Cremallon Q Entombmenl 16d. CEMETERY, CREM CITY /TOWN
<br />Q Removal Q Other (Specl'y)
<br />
<br />16c. DATE (Mo" Day, Yr, )
<br />Se tember 19, 200
<br />STATE
<br />
<br />Westlawn Memorial Park Cemetery,
<br />
<br />Grand Island, NE
<br />
<br />.,.~~-
<br />17a FUNERA~ HOME NAME AND MAI~ING ADDRESS (Street, City or Town, Slate)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />17b. Zip Codo
<br />68801
<br />
<br />APPROXIMATE INTERVA~
<br />
<br />respiratory arrast, or ventricular tibrillation without showinglhe etiology. DO NOT ABBREVIATE. Enter only one cause on a Iins. Add addHionallines if necessary.
<br />
<br />IMMEDIATE CAUSE (Finat
<br />disease or condition resulUng
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />-~~ETo.f~~CON~~l~~n~ l ~
<br />
<br />Onset to death
<br />
<br />I J.-{ aV- .I
<br />--'-_.~_.
<br />et to death
<br />
<br />Sequentl.lly list oonditlons, If (b)
<br />.ny,l..dlngloti1e<au..llatod -----OUe TO, OR AS A CONSEQUENCE OF;
<br />online..
<br />Enterlhe UNDER~YING CAUSE
<br />(dl..... or Injury th.t InltlOled (c)
<br />the oven,. resulting in d..th)
<br />LAST
<br />
<br />C Op 1)
<br />
<br />Or'lset to death
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />Id)
<br />
<br />'.---.-
<br />PART II, OTHER SIGNIFICANT CONDITIONS.Conditions contribuling to Iha dealh but nol ra,ulling in Ihe underlying cau.a given In PART I.
<br />
<br />G I" b/~.{d,
<br />
<br />19. WAS MEDICA~ EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />YES Q NO
<br />
<br />20, IF FEMA~E: 210, ~NER OF DEATH 21 b, IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />Q Not pregnant within past year ~alural 0 Homicide l:I Driver/Operator
<br />Q YES IX NO
<br />Q Pregnanl 01 lima 01 doath Q AccldantQ Pending Inve.tigation Q Passengar r<
<br />
<br />Q Not pregnent. but pregnont wilhin 42 dayo 01 deeth Q Suicide Q Could not b. dalermined Q Pedestrlon 21d. WERE AUTOPSYFINDINGS AVAI~AB~E TO
<br />
<br />o Nor pregnent, but prognent 43 days to 1 yeer belore doath Q Other (Specify) COMP~ETE CAUSE OF DEATH?
<br />
<br />o Unknown if pregnant within the past year 0 YES ~ NO
<br />
<br />~DAT'E OF INJURY (MO" Day, Y'~)-L~-OF INJUR: 22c, P~ACE OF INJURy.A! home, tarm. streOI, laclory, olflce building, construcllon oila, etc, ISpeclty)
<br />
<br />
<br />. -.,:"~AT_i-~ ,btSiiii8e HOW.""'l16Uil'lll>'-:::;;' . -- ,
<br />Q YES Q NO
<br />
<br />221. lOCATION OF INJURY. STREET & NUMBER, APT NO.
<br />
<br />CITYrrOWN
<br />
<br />ST!>JE
<br />
<br />ZIP CODE
<br />
<br />240, DATE SIGNED IMo" Day, Yr.)
<br />
<br />24b. TIM~ OF DEATH
<br />
<br />m
<br />
<br />ll~i
<br />H~
<br />a.~ C ~
<br />H~i5
<br />.!~'"
<br />,20:8
<br />o ~
<br />Uo
<br />
<br />m
<br />
<br />~4c. PRONOUNCED DEAD IMo., Doy, 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 />the time, date and place and dUB to the cause(s) stated. (Signature and Title) ...
<br />
<br />25, DIDTOSACCO USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />."~._ 0_. NO Q PROBAB~Y Q UNKNOWN _,",,? YES . ~NO ___ .~"~ot Applicable il260 10 NO 0 YES Q NO
<br />27. NAME, TIT~E AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo 01 Print)
<br />Travis Hageman M.D. 729 N. Custer Ave., Grand Island, NE. 68801
<br />
<br />2So, REGISTRAR'S SIGNATURE 2Sb. DATE FI~ED BY REGIST~~~o"fY'i') 2008
<br />
<br />
<br />HHS-61 11108 lfifiOll1)
<br />
|