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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H~ALT,I-k ND,~-f~/Q1AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECDRp ON FILE WITH THE NEBI~fF511;4' ~~~d~TM~~~T pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL. DEPOSITOR?f F~'12'' V77',~Co'F~E~/Q~R,D~a ~
<br />DATE OF ISSUANCE ~~t~~~G~ vl~ ' '~
<br />09/03/2009 2 0 0 9 0 9~ 7~ ~ A 5~,~tST ~~Rr~~s.r".BAR
<br />-~PA~iTME7~IT OF' MEAT 1?~ND
<br />LINCOLN, NEBRASKA ~ `~1LlMr~l~ SERVI~'~'.• ~ ~,' ..~
<br />STATE bF NEBRASKA - DEPARTMENT bF HEALTH AND HUMAN SERO E ~~~ 1 ~f ~ ~ \t~ ~•~^
<br />CERTIFICATE OF DEATH '"~ ~ `~. ,/~„~.Yf .,~° ~,`~-~" .~ 09 01902
<br /> 1. DECEDENT'$•NAME (First, Middle, Last, Suffix) 2. SE ~~ ~.AEtTE OF DEATH (Mo., Day, Yr.)
<br /> Donald Walter Uden Male August 23, 20D9
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Oast BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY e. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Juniata, Nebraska 75 August 6, 1934
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 507-48-2943 HOSPITAL ^ Inpatient OTHER ®Nursing HamalLTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Institution, glue street and number) ^ EWOutpatlent ^ Decedent's Homa
<br />a
<br />
<br />~
<br />Madonna Rehabilitation Hospital DOA Other (SpecHy)
<br />^ ^
<br />~ 8c. CITY pR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />S Lincoln 68506 Lancaster
<br />J ea. RESIOENCE•STA7E 8b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Adams Juniata
<br />z
<br />~
<br />9d. STREET AND NUMBER
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />eg. INSIDE CITY LIMITS
<br />~`
<br />a, 7800 North Conesto a Avenue 6$955 ^ YES ®No
<br />~
<br />v 10a. MARITAL STATUS A7 TIME OF DEATH ®Marcied ^ Never Married 79b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />m
<br />^ Marcled, but separated ^ Widowed ^ glvorcad ^ Unknown
<br />Geraldine Lange
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />~ Walter Uden Ida Dieken
<br />°'
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. 14a. INFORMANT-NAME t4b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk-) v@9 02/04/1957-11/04/1958 Geraldine Uden Wife
<br />~ 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNgTURE 186. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />ti ®l3urlal [~] Donatign Michael Davis 1189 August 27, 2009
<br /> ^ Cremation ^ Entombment
<br /> 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br /> © Removal [~ Other (Specify)
<br /> Concordia Cemetery Juniata Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Coda
<br /> Livingston-Butler-Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 68901
<br /> U E OF DEATH See instructions and exam les
<br /> 18. PART I. Enter the chain of avente-.(Iiseae6a, injuYies, or compllratlone4hat directly nuaad the death. DO NOT enter terminal avanta such as cardiac arreal, ! APPROXIMATE INTERVAL.
<br /> reopiretory arreal, or ventricular flbrillatlen without ahowlnp the etlplopy. DO NOT ABBREVIATE. Enter only one cause an a Ilna. Add addhlonal Ilnoo If nacetaary.
<br /> IMMEDIATE CAUSE: Onset t0 death
<br /> IMMEDIATE CAUSE (Final a) Endocarditis 4 Weeks
<br /> dlaease or condl[Icn resulting
<br /> in deatnj DUE 70, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially Ilat contlitbns, it t])
<br /> any, leading to the cause Ilatad
<br /> on Ilea a. pUE TO, OR AS A CONSEQUENCE OF: ! Onset t0 death
<br /> Enter the UNDERLYING GAUSE C)
<br /> Idlseasa or In!ury that Inelatad
<br /> the events resuhing in death) pUE TO, OR A5 A CONSEQUENCE OF: ! onset to death
<br /> LpsT d)
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions conVlbuting to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDIGAL EXAMINER
<br /> Hepatic Failure, Renal Failure OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />~
<br />W
<br />LL 20. IF FEMALE: 21 a. MANNER OF pEATH 21 b. IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pregnant within pant year ®Naturel ^ Homicide ^ DdvarlOparator ^ YE$ ® Np
<br />U ^ Pregnant at Dme of peach ©pCCitlent ©Pendinp Investlgatitln ^ Paaaonpor
<br /> © Not pregnant, but pregnant within 42 days of death gulclde Could not be determined
<br />^ ^ ^ Podoatrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />70 COMPLETE CAUSE OF DEATH?
<br /> ©Not pregnant, but pregnant 48 days to 1 year before death ©Othar (Specify)
<br /> ^ Unknown If pro9nant within the peat year ^ YES ^ Np
<br />Q
<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 />i3
<br />,~ 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~'
<br />^ YES ^ NO
<br /> 22f. LOCATION pF INJURY • STREET & NUMBER, APT.NO. CITY(rOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 246. TIME OF DEATH
<br /> ~' w August 23, 2009 ~ ~ a
<br /> r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME pF DEATH ~ ~' k ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONDUNCED DEAD
<br /> g ~ Z Au ust 27, 2009 08:20 PM ~- ~ e =
<br />
<br />0 Sd. To the beat of my knowledge, death occurcad at the time, date and place
<br />~ o
<br />$ ~
<br />$
<br />24a. On the bawls of eaamination an0/or Investlpation, In my opinion death occurred at
<br /> and due to the cauwlo) orated. (Signature antl Tit16)
<br />~ ~ the lima, data and place and due to the cauoelal atitatl. (Signature and TRI9)
<br /> "
<br />Richard French, MD ~ ~ a
<br /> 2S. DID T08ACCp U$E CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ^ YES ®NO Not Applicable If 28a Is NO ^ YES ^ NO
<br /> 2 . NAME, TL AND ADDRE F I I ype or r nt)
<br /> Richard French, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br /> 28a. REGISTRAR'S SIGNATURE
<br />~ `~ ~- ~~ 28b. DATE FILED BY REGISTRAR IMo., Day, Yr.)
<br />ust 31
<br />Au
<br />2009
<br /> g
<br />,
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