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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND.,HVVAN'SERVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKXOE'P,IA~A qr HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VFTXL` LI7~a r,~
<br /> r., V Y
<br /> DATE OF ISSUANCE ~ `ti' a l
<br /> 01/13/2009 2 0 0 9 0 2 7 0 5 ASit-STAM
<br /> A$9IS'TAN
<br /> DEP,~R'TM~~71; F~~AI TI~a~.9ND ,
<br /> IV SEWIk'S
<br /> LINCOLN, NEBRASKA HUM~
<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICIyS .„0 /x."09 00008
<br /> CERTIFICATE OF DEATH ''ti `."0.,
<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX / f,',GATE OF,pEAT•M64Mo., Day, Yr.)
<br /> Raymond Del Ha enmaster Male Janua 6,2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE -Last Birthday Ob. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE,
<br /> Dodge City, Kansas 81 Janus 3, 1928
<br /> 7. SOCIAL SECURITY NUMBER as. PLACE OF DEATH
<br /> 515-12-2531 HOSPITAL © Inpatient OTHER ® Nursing Home/LTC L] Hospice Facility
<br /> 8b. FACILITY-NAME (If not Institution, give street and number) ❑ ER/Outpatlent L] Decedent's Home
<br /> Grand Island Veterans Home ❑ ODA ❑ Other (Specify)
<br /> t~
<br /> w 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br /> Of
<br /> Grand Island 68803 Hall
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> w Nebraska Hall Grand Island
<br /> 7 9d. STREET AND NUMBER e. APT. NO. 9f, Zip CODE 9g. INSIDE CITY LIMITS
<br /> 24 Via Trivoli 68803 ® YES NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH [@ Married ❑ Never Mamled 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> L] Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown LaVina Campbell
<br /> 11, FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'$•NAME (First, Middle, Malden Surname)
<br /> Francis Ladel Hagenmaster Eula Pearl Brill
<br /> c' 13. EVER IN U.S. ARMED FORCES? Give dates of service It Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, No, or Unk.) Yes 04/25/1946-04120/1947 LaVina Ha enmaster Wife
<br /> g 15. METHOD OF DISPOSITION 162. EMBALMER-SIGNATURE 16b, LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> Burial L] Donation Not Embalmed January 6, 2009
<br /> ® Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> C] Removal ❑ Other (Specify) Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATE ee nstruct ons an exam es
<br /> 13. PART I. Enter the chain of aysms,-diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest, or vantelcolar fibrillation without showing the etiology. DO NOT AEBRSVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Aspiration Pneumonia 1 Week
<br /> classes or aondnuon resulting
<br /> in aeatn) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, if b) Dementia >1 Year
<br /> any, leading to Me cause listed
<br /> on line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE c) Dysphagia 6 Months
<br /> (disease or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> LAST d)
<br /> 18, PART It. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> Diabetes Mellitus, II; Hypertension. OR CORONER CONTACTED?
<br /> ❑ YES ® NO
<br /> LU 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> F ❑ Not pregnant within past year ® Natural ❑ Homicide © Driver/Operator ❑ YES ® NO
<br /> ❑ Pregnant at time of death ❑ Accident L] Pending Investigation ❑ Passenger
<br /> ❑ Not pregnant, but pregnant within 42 days of death © Pedestrian El Suicide © Could not be tlatarmlrrod 21d. WERE AUTOPSY FINDINGS AVAIIAaLE ❑ Not pregnant, but pregnant da days to 1 year before death ❑ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> L] Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> E
<br /> 8
<br /> .9 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> 0
<br /> I.- YES NO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) Y 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> January 6, 2009
<br /> r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> , 0
<br /> Janus 6 2009 07:20 AM
<br /> C 3d. To the best of my knowledge, death occurred at the time, date and place 24a. On the basis of examination and/or Investlgation, in my opinion death occurred at
<br /> and due to the cause(s) stated. (Signature and Title) $ the time, date and place and due to the cause(s) stated. (Signature and Title)
<br /> Jennifer King, MD
<br /> 25. DID TOBACCO USE CONTRIBUTE T THE DEATH? 268. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES [0 NO Nat Applicable if 26a is NO L] YES ❑ NO
<br /> 27. NAME, TITLE ANUWUW40 OF GIEKTIFIEK 1PHY51CIAN, CORONER'S PHYSICIAN ON (;;UUNTY ATTOKNE.. I
<br /> ype or Print) Y) (T
<br /> Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28x. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> January 6, 2009
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