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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT,H~A9b'fi& WAN ER VICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS'tiGq~DPR TMf y~6iff'HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR, 'V~T,(4L RECOWF ,l '
<br /> DATE OF ISSUANCE rtJ
<br /> STANLEY ,S QOPIFR.:
<br /> MAY 2 6 2009 200907511 Ta1T RGJTA.
<br /> DEPAPTM r~lr HNft,f ,6tp
<br /> LINCOLN, NEBRASKA HmAN. S VI . S
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO ( n
<br /> CERTIFICATE OF DEATH 9 , 2,34 4 4
<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo„ Day,Yr.)
<br /> Clara Ritter Female April 13, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Lasl Blrlhday 5b. UNDER 1 YEAR $c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> Kennard, Nebraska (Yrs.) MOS. DAYS HOURS MINS.
<br /> 90 November 13, 1918
<br /> 7. SOCIAL SECURITY NUMBER 8e. PLACE OF DEATH
<br /> 508-03-9773 _ HOSPITAL: X) Inpatient 91EH ❑NursingHome/LTC ❑HospiceFacility
<br /> Bb. FAC!LiTY•NAME (If act institut6;n, give $treat and number)
<br /> ❑ ER/Oulpaliem ❑ Decedent's Home
<br /> St. Francis Medical Center ❑ DO, pothersaecl
<br /> ( h)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bid. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> ga. RESIDENCE STATE Bb. COUNTY k. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER 9e. ApT. NO 911ZIPCODE 9g. INSIDE CITY LIMITS
<br /> 1328 Howard Place 68803 1G) YES Q NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH I Married ❑ Never Mauled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) II wile, give maiden name.
<br /> f '
<br /> ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br /> Charles E. Ritter
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle,
<br /> Malden Surname)
<br /> e Ray Casey Lillian M. Hansen
<br /> 13. EVER IN U.S. ARMED FORCES? Give dales of s=Yeslu, ORMANT•N AME- 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, or unk.) No Charles E. Ritter Husband
<br /> 15. METHOD OF DISPOSITION t6a-EM L R•SIGN TU 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br /> QdBurlal ❑Dondtion April 17, 2009
<br /> Q Cremation ❑ Entombment 16d. CEMETERV, CRE A RY OR OTHER LOCATION CITY /TOWN STATE
<br /> to ❑Removal ❑Other(Specify) 1. 0. 0. F. Cemetery Gregory, South Dakota
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b, Zip Cade
<br /> Apfe1 Funeral Home, 1123 West Second, Grand Island, NE 68801
<br /> x,.. e
<br /> 18. PART I. Enter the chalk of events••disea9es, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> & respiratory arrael, or ventricular libdllalion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines II necessary.
<br /> _ IMM E: I onset to deal
<br /> IMMEDIATE CAUSE (Final (a)
<br /> d
<br /> Indeath) resses or condition resulting DUE TO, OR AS A CONSEQUENCE OF,
<br /> I onset le death
<br /> Sequentially list conditions, if (o) I
<br /> any, leading to the cause Ileted
<br /> 4 DUE TO, OR AS A CONSEQUENCE OF:
<br /> on line a. I onset to death
<br /> y
<br /> Enterlhe UNDERLYING CAUSE 1
<br /> (disease or Injury that Initiated (c) I
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF
<br /> LAST I onset to death
<br /> I
<br /> S; (d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to The death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> C") e k-( dVVft~. ❑ Yes W"NO
<br /> 20. IF FEMALE: 21a.MANNEROFDEATH 2
<br /> a~1b. IF TRANSPORTATION INJURY 21c.WA3ANAUTOPSY PERFORMED7
<br /> t- k;K01 pregnant within past year ❑ Natural ❑ Homicide ❑ Drlver/Oparalor
<br /> r0
<br /> C3 Pregnant at time of death ❑ Passenger ❑ YES 3140
<br /> i'•.. ❑ AccIdemQ Pending Investigation
<br /> r., Q Not pregnant, but pregnant within 42 days of death C1 ❑ Suicide ❑ Could not be determined Pedestrian
<br /> o 21d.WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> y ❑ Not pregnant, but pregnant 43 days to t year before death ❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br /> Unknown if pregnant within the past year ❑ YES Q'ITO
<br /> SFr;, Unknown
<br /> 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 /> ~l 22d. INJURY AT WORK? 228. DESCRIBE HOW INJURY OCCURRED
<br /> 1F
<br /> ❑ YES' JO
<br /> 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/rOWN - STATE ZIP CODE
<br /> =;L
<br /> }p', 23a. DATE OF DEATH (Mo., Day, Yr,) u - $ 24a. DATE SIGNED (Mo., Day, Yr.) 241h, TIME OF DEATH
<br /> April 13, 2009 m
<br /> } 231b. DATE SIGNED (Mo., Do , Yr. 23c, TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Da Yr.) 24d. TIME PRONOUNCED DEAD
<br /> Eaz Aril 14, 2~0 16:07 pma r,
<br /> 23d. To the bas 1 my k wle e, death occurred at the lima, dale and place $ m
<br /> g - rd~ a cau e s s led. 51 nature and Thle • 240. On the basis of examination and/or investigation, In my opinion death occurred at
<br /> E O 000
<br /> { h° O • g ) C the time, data and place and due to the cause(s) staled. (Signature and Tills) T
<br /> e' 25. DID TOBACCO U E ONTRIBUTE TO THE DEATH? 28d. HAS ORGAN OR TISSUES DOONNATION BEEN CONSIDEREU7 1:Ob, WAS CONSENT GRANTED? _
<br /> 4 Q YES ❑ 0 CJ PROBABLY ❑ UNKNOWN ❑ YES W N, NPt Applicable If 28a is NO ❑ YES
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or PHni)
<br /> Ryan Crouch D.O. 800 Al ha Ave., Grand Island, NE 68803
<br /> 28a. REGISTRAR'S SIGNATURE
<br /> 28b. DATE FILED BY REGISTRAR (Me., Day, Yr.)
<br /> APR 17 2009
<br /> HHS-61 11/03 (55061)
<br />
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