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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAItSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REffOiioON Fll...l!'~ITH
<br />THE-NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTJPS. St;ciiON, 'wHi!;ifl$
<br />THE LEGAL DEPOSITORY FOR VITAL. RECORDS. ;;'"' ::C~'J ,... '-"'f'>'-"{="'~,-
<br />
<br />DATE DF ISSUANCE ~Ti~~~i 0,
<br />
<br />APR J 6 2006 2 0 0 90 12 6 3 ASSI$,rAN't..sT~rE'REGlsritARf:
<br />LINCOLN, NEBRASKA HEALTl-fAND--,.ti)~ERfIlCES'
<br />~.,: ~~,~.~ -"':;" ...:::.,:.:~...t:..;, :.,; _G'~
<br />
<br />1. D~C~D~NT'S'NAM~ (First,
<br />Don
<br />
<br />Middle,
<br />Ronald
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />3. DAT~ OF DEATH (Mo., D.y, Yr.)
<br />
<br />A p r i 1,~~.L~Q2_6 _
<br />
<br />Rosenthal
<br />
<br />.".----.--1. .....--
<br />5.. AGE..L....t Blrthd..a...Y.. 5...b.... .U. .N. DE. R 1 YEAR
<br />(Yrs),? 9___. ~O~J DAYS
<br />
<br />
<br />8a. PLAC~ OF D~ATH
<br />
<br />50. UNDER 1 DAY 8. DATE OF BIRTH (Mo" D.y, Yr.)
<br />
<br />:~~:c:- F e.b r ua.~~9~..~9 2 7
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />~JJJfalo Count
<br />7. SOCIAL SECURITY NUMBER
<br />506-30-2602
<br />
<br />Nebraska
<br />
<br />illi Inpationt
<br />
<br />QIJ:til: 0 Nursing Home/LTC 0 Hospico Facllily
<br />
<br />~:
<br />
<br />8b. FACILlTY.NAME (II not institution, give street and number)
<br />
<br />Francrs-- Me-ulcaI Ce-nter
<br />
<br />_ .Q i:RlOutp.tie<ll --- -
<br />
<br />o Deoedonlil Hom.
<br />
<br />U !XVI 0 Olher (SpeolfyL.________.
<br />80. CITY OR TOWN OF DEATH (Include Zip Cod.) 8d. COUNTY OF D~ATH
<br />
<br />Islan..cL_.
<br />9.. RESIDENCE-STATE
<br />Nebraska
<br />
<br />H a 11__
<br />
<br />88 3
<br />9b. COUNTY
<br />
<br />90. CITY OR TOWN
<br />
<br />Grand
<br />
<br />Island
<br />
<br />Hall
<br />
<br />9d. STREET AND NUMBER
<br />2010 Pioneer
<br />
<br />
<br />99. INSIDE CITY LIMITS
<br />]YJ YES 0 NO
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />Blvd.
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH !;XM.rriod 0 N.v.r Marrl.d lOb. NAME OF SPOUSE (Flr.t, Middle, Le'l, Sufllx) II wife, give m.lden neme.
<br />
<br />o Married, but soparatod 0 Widow.d 0 Divorced 0 Unknown
<br />
<br />
<br />Scott
<br />12. MOTHER'S-NAME (First,
<br />
<br />lara
<br />
<br />11. FATHER'S.NAM~ (Flrsl,
<br />
<br />Middle,
<br />
<br />L.st,
<br />
<br />Mlddie,
<br />
<br />Maiden Surname)
<br />
<br />fei~~olrNu~k~ :7~ /:;~-~~;:~ S:~~I~~~[:.I:~~~h;~N~M~ y
<br />
<br />15. METHOD OF DISPOSITION MBALM~R.SIGNATUR
<br />o Burial 0 Donation ~
<br />
<br />Widd
<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
<br />160. DATE (Mo., Day, Yr.)
<br />.J i 1 _1lL. 2 0 0 6
<br />STATE
<br />
<br />J. Rosenthal
<br />16b. LICENSE NO.
<br />1328
<br />
<br />:I{) Cremation 0 Entombmenl
<br />o Remov.1 0 Other (Specify)
<br />
<br />
<br />CITY / TOWN
<br />
<br />Central Nebraska Crematidn Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDR~SS (Stroot, Cily or Town, State)
<br />11 Faiths Funeral Home,2929 S. Locust St.,Grand
<br />
<br />
<br />PART I. Enter the chain of BventsndissasBs, Injuries, Of compllcatlons.-tllat directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />respiralory arrest, or ventrioular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enler only one oause on a line. Add addlllonallln.. II neoesoary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />(e) Cnn.~''a..<:''
<br />
<br />~~\ 0....
<br />
<br />onset to death
<br />\
<br />h'\f\U~J
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dleease or condition re.ultlng
<br />In dealh)
<br />
<br />Sequentl.lly list condlllons, if (b) \"h...IC\..~s to D
<br />.ny, leading to the cau.ollsted -----OUETO~.~~.AS ';'-CONS~QUENCE' OF:
<br />on line 8.
<br />Enter the UNDERLYING CAUSE () · D "
<br />(dlsesoeorlnjurythatlnltlated (c) r O...\k.~'\,).. ..\S-ec\.S-e
<br />thee"entsresulUng In death) -----oiJEro;- OR AS-ACONS~Q~NCE'ciF-;- -- ....--
<br />LASr
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I OMelia death
<br />
<br />...:~.~-
<br />
<br />I onsello death
<br />
<br />: 11€i\d'
<br />
<br />L__ _____.
<br />I onset to death
<br />
<br />.: C:t: s
<br />
<br />(d)
<br />
<br />{1cu~. Rer.c\\ ~"'\.\~!S,.__""__..
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS. Conditions contributing 10 Ihe de.th but not resulllng In tha underlying cause givon In PART I.
<br />
<br />19.WAS MEDICA[ EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />U YES CT""NO
<br />
<br />j2lcJ)Q\~S_ -....J .'-:C\~~\)_,).J!h~LR{.y,~ 110J'9:'1-l
<br />
<br />20.IF FEMALE: 21.. MANNER OF DEATH
<br />o Natural 0 Homicide
<br />
<br />IY\G- US
<br />
<br />21b.IF TRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operalor
<br />
<br />o p.ssenger
<br />
<br />Q Nol pregnant within pasl year
<br />o Pregnant at time of de.th
<br />o NOI pregnant, but pregnant wllhln 42 d.ys of de.lh
<br />U Not pregnant, but preananl43 days 10 1 year before death
<br />o Unknown if pregnant within the past year
<br />
<br />Xl NO
<br />
<br />DYES
<br />
<br />o AocldentO Pending InvMllgetion
<br />o Sulolde 0 Could not be dotormined
<br />
<br />o Pedestrian
<br />
<br />21d. WERE.AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o Olher (Specify)
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, f.rm, stro.l, f.ctory, offloe building, construollon olte, elo. (Specify)
<br />m
<br />
<br />22d.I:U:~:'~;~;~ _^ l. :;~ D~:C~:E HOW-INJURY O~~~R_R~D_.^_ .
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP COD~
<br />
<br />z
<br />~~
<br />]!:!
<br />,,!e
<br />D.J::~
<br />E"-z
<br />8 g>o
<br />,8'6
<br />o ii
<br />.....11
<br />
<br />230. DAT~ OF D~ATH (Mo., Day, Yr.)
<br />~_pril 13, 2006
<br />
<br />m
<br />
<br />24.. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />z>-
<br />~~~
<br />1llii'"
<br />H~
<br />c.a.. i4: ~
<br />g~t~
<br /><>wZ
<br />.llz=>
<br />00
<br />~a:u
<br />o ~
<br /><>0
<br />
<br />
<br />A.m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNC~D D~AD
<br />m
<br />
<br />24e. On Ihe basis 01 examination and/or Invesligallon, In my opinion death ooourred at
<br />the time, date and place and due 10 the cause(s) stated. (Signature and Title) l'
<br />
<br />N/A
<br />
<br />Nol Applicable il 28a is NO 0 YES 0 NO
<br />
<br />26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />~
<br />
<br />26b. WAS CONS~NT GRANTED?
<br />
<br />o Y~S IkI"NO 0 PROBABLY 0 UNKNOWN 0 YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTOFtr-ifV)'(Type or Print)
<br />Kimberly Mickels,M.D. 729 N. Custer ve, Grand
<br />
<br />Island,
<br />
<br />NE
<br />
<br />68803
<br />
<br />28e. R~GISTRAR'S SIGNATUR~
<br />
<br />
<br />28b. DAT~ FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />APR 2 0 2006
<br />
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