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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN4 k1W1b~gA(~ERVICES, IT CERTIFIES
<br />- THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA'D~P,Ah?~~1~lal „ ~1, F l-fEALTH AND
<br />'~ HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V1'j'.4L~R~CpRDS ,. ' t
<br />~i r ~~ 7~
<br />DATE OF ISSUANCE /~`~~ ~~• ~~~ ',,
<br />ST?1 /III EY S. CC70P~R ' ~ °. ~ : ' ,
<br />12/24/2009 2 010 01213 ASSISTAN7~;,~7'A~~E~t~QIS1"R,~'FI; ~ ;
<br />DEp,4RfMElV~7~ (~lF~hfEi4L`f~V ;4NQw~, °,'
<br />LINCOLN, NEBRASKA HI1~1N~,N''$ERVI"GES' "" `
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERV~~& ~; ~t ,(e'r'r { ~~ r ~ ? , • ~~ ~. • C Og ~3~~3
<br />CERTIFICATE OF DEATH ~ ~ ... ' '"
<br /> 1. DECEDENT'S•NAME (Flrat, Mlddle, Last, Suffix) 2. SEX '.K t ~ 3f.,~ipT OF'DEA. ~(Mo., Day, Yr.)
<br /> Ma Jean Cadwalader Female " ~ . ~.Decem'be"r 21, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday q. UNDER 1 YEAR 5c. UNDER 1 DAY e. DATE OF BIRTH IMo., Pay, Yr.)
<br /> (Ym•) MOS. DAYS HpUR3 MINE.
<br /> Merna, Nebraska 76 November 25, 1933
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE pF DEATH
<br /> 507-36-3401 HOSPITAL ®Inpatient OTHER ^ Nursing Noma/LTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (It not Institution, give street and number) ^ ER/Outpatlent ^ Decedent's Home
<br />
<br />~
<br />U Saint Francis Medical Center ©DoA ^ Other (Specify)
<br /> CYI'Y01["T¢oVN~DEATFfiiRibrudirxlt5cvda) _ _ _ -.- _ ___r-_._~ Bd.COUhtTYOF~A~+i--~-- ~ _ ._ v_ _ ~:
<br /> Grand Island 688D3 _ _ Hall
<br />J 9a. RESIDENCE-STATE 96. COUNTY 9C. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 4151 S rin view Drive 68803 ®ves ^ No
<br />~ 1Da. MARITAL STATUS AT TIME OF DEATM ®Marrlad ^ Never Married 10b. NAME OF SPOUSE (First, Mlddle, Last, Suffix) Hwlfa, give maiden name
<br /> ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Roy D Cadwalader
<br />
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MpTHER'S•NAME (First, Mlddle, Malden Surname)
<br />~ JDSeph Wanitschke Dorothy Karnes
<br />
<br />~-
<br />
<br />E 19. EVER IN U.S. ARMED FORCES? Give dates of service ff Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />~ (Yea, Nd, or unk.) NO Roy D Cadwalader Husband
<br /> 15. METHOD pF DISPOSITION 18a. EMBgLMER.SIGNATURE 186. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />~ ®Burial ^ ponado" Derek Apfel
<br />1240
<br />December 28
<br />2009
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TpWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1Yb. Zlp Code
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU E F DEATH See instruct ohs an exam es
<br /> 1a. PART I. Enter the chain of events--dlasaa9p, Injurlea, qr cgmpllWtlgna-that directly cau6ad th. death- DO NOT enter trnninal rvrnta ouch as cardiac arreal, APPROXIMATE INTERVAL
<br /> reapuatory arrest, qr vantdcular 96rlllatlgn without showing [hs e[lolggy. Dp NQ7 ABBREVIATE. EMer only one cauw On A Ilse. Add additional Ilnei If necessary.
<br /> IMMEDIATE CAUSE: onset ro death
<br /> IMMEDIATE CAUSE (Final a) Pneumonia ;One Week
<br /> dtNAie of COitdhlOn roiulting
<br /> In denhj DUE 70, OR AS A CONSEQUENCE OF: onset to death
<br /> sequentially Ila<condltlona, If b) Metastatic Colon Cancer 12 Years
<br /> any, lading tq the cause Ilydad
<br /> on Ilns a. DUE TO, OR AS A ¢ONSE4UENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> Idiiease Or Injury ttlat Initlahd
<br /> the events roiumng in death) DUE TO, pR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 78. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />~ ©YES ®NO
<br />~ 2g. IF FEMALE: 21 a. MANNER OF DEATH R1b. IF TRANSPORTATION INJURY R1c. WAS AN AUTOPSY PERFORMED?
<br /> ^ NOt prognant wllhin plat year ®Natural ©NomlCitle ^ DrNerlOparotor
<br /> ^YES ®NO
<br />~ ^ Prognaln at time of death ^ Accident ^ Panding Inveaflga[Ign ^ Paasangar
<br />
<br />~ ^ Not pregnant, but pregnant wnhln 42 days of death
<br />^ Suicide ^ Could not be determined ^ Padastdan R1d. WERk3 AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, but prognant 43 days to 1 year before death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH
<br /> ^ Unknown If pregnant wllhin the pant year ^YES ^ NO
<br />
<br />a
<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 />
<br />°~ 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^ YE$ ^ NO
<br /> RRT. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY(rOWN STATE ZIP CODE
<br />- -- - - 23a. DATE OP DEATH IMd., Day; Yr.- ~ ~-' ~ - ~ ~'---- `- - ~ 24s. DATE SIt:NEp(NAb., Day; Yy.) - ~ 24b. TIME DF DEATH
<br /> ~' ~ December 21, 2009 S ~ ~
<br /> r Rib. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ ~ = December 22, 2009 05:06 PM ~ a
<br /> 3 6 O
<br />~
<br />g 9d. To the bas[ of my knowledge, death gccurrad at the time, data and plats
<br />
<br />~ 3 ~
<br />w tae. Qn the basin of examination andlor Inveatigatlon, In my Oplnlon death occurred M
<br />~
<br /> o O and due to tba Caute(i) stated. (Signature and Tttlej ~ p the tune, data and place and due to the CAUieli) abtatl. (Signature and Title)
<br />~
<br /> s Gary Settje, MD g `o
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATHS 28a. HAS ORGAN pR TISSUE DONATION BEEN CONSIpEREDT 28b. WA$ CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable H 28a Is NO ^YES ^ NO
<br /> 2 I L N I H 1 IAN, Y 1 AN I AN N )( ype or rant)
<br /> Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 6$$03
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> December 23, 2009
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