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STATE OF NEBRASKA
<br />r
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H~,4LTM AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N,~'BRASFt'~F DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR1~,fOR Vj~AL':R~CORDS.
<br />DATE OF ISSUANCE /~r~ ~ ~ ~~
<br />n c n C Si'ANk~YSr COOrnEft ''
<br />APR o~ Zaa9 ~ O O 9 O 6~ V 5 ASSI.~~,ANT STATErREGI$'~I~AR
<br />`:~EPAR7•MENT OF H~A,t;rtt AND
<br />LINCOLN, NEBRASKA HIfMA,~J'SERtiICE$ , •• . '
<br />STATE OF NE8RA5KA - gEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE: AND SUPPORn ~y h
<br />CERTIFICATE OF DEATH u ~ ~ ~ U U
<br />1.DECEpENT'3-NAME (First, Middle, Last, Suf11x) 2. SEX 3. DATE OF DEATH(MV.,Day,Yr.)
<br />Raymond Christian Engel Male September 26, 2008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lest Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 pAY 8. DATE OF SIRTH (Mo., Dey, Yr.)
<br />(Yrs.) 95 MpS. DAYS HOURS MINE. September 5, 1913
<br />Doniphan, Nebraska
<br />7, SOCIAL SECURITY NUMBER ^18d. PLACE OF DEATH
<br />50~-18-60b5 I HDSPiTAL: ^ InpXtlenl ~ NursingHvme/LTC ^HdsplaeFacility
<br />86. FACILITV•NAME (If not instllution, glue street and number)
<br />Q ER/0utpetlent ^ Decedent's Home
<br />Good Samaritan Nursing Home ^ pOt ^Other(Speclry)
<br />8C. CITY OR TOWN OF pEATH (Include Zip Cvda) ed. COUNTY OF DEATH
<br />Wood River b8$83 Hall
<br />Be. RESIDENCE•STATE gb.000NTY Bc.CITVORTOWN
<br />Nebraska Hall Wood River
<br />9d. STREETANDNUMBER 9e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />3731 S. 90th Rd. _ b8883 ^ YES ~I No
<br />t0a. MARITAL STATUS AT TIME OF bEATW ^ Marrlad ^ Never Married 10b. NAMF OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name.
<br />^ Mewled, but separated G~Widowed Q Dmorced ^ Unknown
<br />11. FATWER'S•NAME (First, Mlddl6; Last, Suffix) 12. MOTHER'S•NAME (First,
<br />Emil Benjamin Engel Nellie
<br />13. EUER tN U.S. ARMED FORCES? Giva dates of service if yes. 14a. INFORMANT•NAME
<br />(va6, nd, dr ank.) NO .Tanna Cornelius
<br />15. METHOD OF bISPOSITION 16a MB MER-SIGNAT (~ J~ -
<br />~Burlel ^ Donation /j~/'~
<br />^ Cremation G Entombment 18d. CEMETER REMATORY OR OTH LOCATION
<br />^Removal ^Other(5pecify) Cedarview Cemetery
<br />18b. LICENSE NO.
<br />CITY /TOWN
<br />Middle, Maiden Surname)
<br />Almeda Brit_tain
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />18c. DATE (Mb., pay, Yr. )
<br />October 3, 2008
<br />STATE
<br />Doniphan, Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slrae6 City orTown, State)
<br />Apfel Funeral Heme, 1123 WesC Second, Grand Island, NE.
<br />78. PART I. Enter the chain of avents••diseases, in)urles, or complicatlona--that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEpIATE CAUSE:
<br />f
<br />IMMEDIATE CAUSE(Flnel lel___ ~~~r~G~MGt~~
<br />dlseaaearcorMltidnneulting DUE T0, OR AS A CDNSEQUENCE OF
<br />In death)
<br />Sequemlallyllstwndlllona,If (b)
<br />arry,laadingtotheceutwllated pUETO,ORASACONSEQUENCEOF:
<br />do Ilse a.
<br />Enter the UNDERLYWO CAUSE
<br />(disease or In)ury that Inldated (c)
<br />thseVenureaultinglndeeth) DUE T0, OR A5 A CONSEQUENCE OF:
<br />LA$r
<br />(d)
<br />18. PART ILOTHER SIGNIFIpCANT pDNDITIDNS-Cdndltians contributing to the death but not resulting in the underlying cause given In PART I.
<br />J t O IA.Qr
<br />20. IF FEMALE:
<br />^ Not pregnant within peat year
<br />Q Pregnant et time of death
<br />^ Not pregnant, but pregnant within 42 days of death
<br />^ Npt pregnant, but pregnant 43 days to 1 year before death
<br />^ Unknown if pregnant within the past year
<br />~--~--~
<br />21a..M~AIN~NEROFDEATH a16.IFTRANSPORTATIDN
<br />.off natural p HOmlClde Q DflVerlOperatOr
<br />^ Accidant^ Pending Inveatigaticn ^ Passenger
<br />^ Pedestrian
<br />17b. Zlp Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />!p 11~OS
<br />I onset to death
<br />I
<br />I
<br />I onset tc death
<br />I
<br />I onset to death
<br />I
<br />1g. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />^ VES ~ NO
<br />21 c. WAS AN AUTOPSY PERFDRMED7
<br />^ YES ~TNO
<br />^ Sulclde ^ Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />-_ -- .32a,DATE..F.D1odi"FM~..~Bay,rr.)~;~ 22o:'YtInE~~fNJURP_ ..
<br />m
<br />22d.INJURYATWORK7 22e.DESCRIBEHOWINJURY000URRED
<br />[] YES ^ NO
<br />GOther(Specify) ~ COMPLETE CAUSE OFDSATH7
<br />^ YES ~NO
<br />_..
<br />;.1'CAGE OFff7NRRAf dome, farm, street, factory, olflce building, construction alto, etc. (Specify) T
<br />22f. LOCATION OF INJURY -STREET 6 NUMBER, APT. N0. CITYnOWN
<br />STATE ZIP CODE
<br />= 23a. DATE OF DEATH (Mo., Day, Yr.)~rl r 24a. DATE SIGNED (Mo., Day, Yr.) 246.TIME DF DEATH
<br />~ ~-aG-~r ~~~ m
<br />~~„ 23b.DATESIGNED(Mo.,Dey,Yr. 23aTIMEOFbEATH ~~ 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) 2ad.TIMEPRONOUNCEDDEAD
<br />°~ - O -~ 9'S5 p m a~a~ m
<br />~ 23d.To the best of my knowledge, death occurred at the time, date and place $ ¢ ~ ~ 24e. On the bests of examination and/ar Investlgatlon, in my opinion death occurred et
<br />~ rte, end due to the cause(s) stated. (Signature end Title) • ~ ~ ~ rho time, date and place end due to the cause(s) stated. (Signature end Title)
<br />8
<br />\ a '' ~ 8 $
<br />~- 25. DIDTOBACCO USE CDNTRIBUTETOTW ATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRANTE07
<br />+` ^ YES ND ^ PROBABLY ^ UNKNOWN ^ YES ~ ND Nat Applicable if 26a is Np ^ YES.~'NO
<br />27. NAME, TITLE AND ADDRESSgFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typevrprlnq
<br />Richard Fruehling M.D. 2116 W. Faidley Ave., Grand island, NE. 68803
<br />~'..
<br />28a. REGI5TRAR'551GNATURE 28b, DATE FILED BY REGISTRAR (Mo., Day, Yc)
<br />OCT 3 2oa~
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