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STATE ~F NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q,Ep,4RTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI]'A1: RECORDS.
<br />DATE OF ISSUANCE ~~~~, • _ ~~ ~~
<br />STANLL?3' S. COOPED
<br />APR a 3 znn9 Q c cc ASSISTANT ~~ATE REGISTRAR
<br />2 0 0 9 O s S O J DEPARTMENT OF HEALTy AIVD
<br />LINCOLN, NEBRASKA HUMAN•~~RVICES
<br />STATE pF NEBRASKA- DEPARTMENT OF HEALTH ANq HUMAN SERVICES FINANCE f'+I!10 SUPPr i ~T
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S-NAME (First, _ Middle, Last, Sufflz) 2. SEX 3. DATE OF pEATH (Mo., Day,Yr.)
<br />Mil_d_red 1,. Engel Female January 31, 2008
<br />4. CITY AND STATE DR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AOE•Last Birthday 56. UNDER 1 YBAp 5c. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br />Doniphan, Nebraska g3 December 12, 1914
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />569-12~-3892 HOSPITAL; ^ Inpatient QD Ei ~ ~Nuraing Wome/LTC ^Hoaplce FgClllly
<br />
<br />8b. FACILITY-NAME
<br />pf not institution, glue street end number)
<br />^ ER/Outpatient ^ DeCedent'sHome- - --
<br />Good Samaritan Centex ^ DpM<, ^Omer(5peciq)
<br />Bc. CITY qR TDWN OF DEATH (Include Zlp Coda) Bd. COUNTY OF DEATH
<br />Wood River 68883 Hall
<br />9a. RESIDENCE-STATE 96. COUNTY gc. GfTY OR TOWN
<br />Nebraska Hall Wood River
<br />9d. STREET AND NUMBER 9e. APT. NO gl. ZIP COOS 9g. INSIDE CITY LIMITS
<br />3731 SOUth 90th Road 6$883 ~ ^YE5 $l NO
<br />ibe. MARITAL STATUS AT TIME OF DEATH ~Marrled ^ Never Married 106. NAME DF SPOUSE (FIre4 Middle, Laet, Suffix) If wife, give maiden name.
<br />^ Married, but separated ^ Widowed ^ Divorced ^ Unknown
<br /> Raymond Engel
<br />11. FATHER'S-NAME (First, Middle, Laat, Sulllx) 12. MpTHER'S•NAME (First, Middle, Mellon Surname)
<br />_ John Harris Anna Graf
<br />13. EVER IN U.S. ARMED FORCES? Give dateaof service i}yes. 16a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />(vas, no, orunk.)Np Ra and En el Husband
<br />15. METHOD OF DISPOSITION i8a. EMBALMER• IGNATURE
<br />,
<br />~" 16b. LICENSE ND. 18c. DATE (Mo., Day, Yr. )
<br />RiBur;al Oponatien .~
<br />..A-IwwA /~z ~ February 7, 2008
<br />^Cramation ^Entom6ment 18d.CEMETERY,CREM ORYOROTHE OCATION CITY/TOWN STATE
<br />^ Removal ^ Other (Specify)
<br /> Cedarview Cemetery, Doniphan, Nebraska
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or7own, State) 17b. Zip Code
<br />A fel Funeral Hnme 1123 West 2nd Street Grand Island., Nebraska 68801
<br />18. PART I. Enter the rJlainzaf events-diseases, InJurlea, or compllcellons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREUTATE. Enter only one cause an a Ilne. Add eddltlonel Ilnes if necessary, I
<br />IMMEDIATE CAUSE: I onset to death
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<br />IMMEDIATE CAUSE(Flnel
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<br />dleeeseacondidonrrsuPorg pUETD,DRA3ACONSEOUENCEOF: I onaettodeath
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<br />Sequendelly Iles condhlons, H (b) •' ~.~~ ~ ~ mar ~ l+N PN ~ rr ` I ~+ Xc ~'° .
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<br />any,leadingtotMuuwllated
<br />DUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br />on Ilne a.
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<br />EttmrIMUNDERLYINGCAt1SE
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<br />(dlsnabrln)urythetlnltlated lc)
<br />iMeventarosuhlttglndeelh) pUE T0, OR AS A CON3EquENCE OF: w.~.
<br />I onset to death
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<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 7g. WAS MEDICAL EXAMINER
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<br />' OR CORONERCONTACTED9
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<br />~{( ~/,1LTGY"f'w~ r
<br />GW• ~~II ^ vas Q No
<br />20. IF FEMALE: 27a.MANNEROFDEATW 27b.IFTRgNSPORTATIONINJURY 21 c;WA5ANAUTOPSYPERFORMEp?
<br />Not pregnant within past year Natural ^ Homicide O prlvedOperator
<br />^ Pregnant at time of death ^ Accident[] Pending Inveatlgatlan
<br />C7Paeaenger
<br />^YE5 ~NO
<br />
<br />^ Not pregnant, but pregnant within 42 days of death
<br />^ Sulclde ^ Could not be determined ^ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Nat pregnant, but pregnant 43 days to t year before death ^ Other (Specify) COMPLETEGAU$EDF DEATH7
<br />^ Unknown if pregnant within the past year G YES ~ NO
<br />22a. DATE DF INJURY (Mb., Osy, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJUFh'•At home, farm, street, factory, stilts building, conatrucdon site, etc. (Spaci}y)
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<br />22d.INJURV AT WORK? 229. DESCRIBE WOW INJURY OCCURREp
<br />^ VES ^ NO
<br />22f.LOCATIONOFINJURY•STREET&NUMBER,APT.NO. CfTY/fOWN ~__ STATE ZIPCOpE
<br /> 23a. DATE OF gEATH (Mo., Day, Yr.) 24a. DATE SIONEp (Mo., Day, Yr.) 24b.TIME OF DEATH
<br />~s January 31, 2008 ~.~~ m
<br />- YY 23b.pATESIGNED(Mo.,Dey,Yr) 23c.TIMEpFDEATH ~~
<br />24CYPRONOUNCEDDEAD(Mo.,Day,Yc)' 24d.TIMEPRpNOUNCEODEAD
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<br />~ 23d.7o the best of my knowledge, death occurred et the time, date and pl a
<br />and due the cause(s) stated
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<br />ndTttle) • rx ~ 0 24e. On the basis of axaminatlCnand/or inveatlgatlon, In my opinion death occurred at
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<br />25.pIpTOBA000USECONTRIBUTETOTHE EATH? 26a.HASORGANORTISSUEDONATIONBEENCONSIpERED7 28b.WASCONSENTGRANTED7
<br />^ YE5 ~ NO [~ PROBABLY ^ UNKNDWN ^ YE9 ~ NO Not Applicable If 28a is NO ^ YES NO
<br />27. NAME, TITLE AND ADpRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or PrlnQ
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<br />2na. REGISTRAR'S SIGNATURE
<br />~ 2Sb. PATE FILED BY REGISTRAR (Mo., Da
<br />y, Vr.)
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