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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HJM N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAF''A~t~l~l~,4'~pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE,. WHICH IS THE LEGAL DEPOSITORY FO.R V7~1 ~€L~,b~~2~,5~ ".~''
<br />~'
<br />DATE OF ISSUANCE ~~,~~~~ 1C7 ~
<br />01 /08/2010 ~ O ~ t7 a ~ `~ ~ ~ ASS~T~4NT,~„T/~~ REG,~STR.AR . '.
<br />DE~A rME11(~}C?~ f 1~L~hl AND
<br />LINCOLN, NEBRASKA HLIM~N SERVIC(~S -
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES?. '-'r r - r' (19 ~3~ 25
<br />CERTIFICATE OF DEATH ` F'' ~ !
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<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX , 3~DATE~OF DEATH (Mo., Day, Yr.)
<br /> Rand William Sindelar Male December 29, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last lilRhday b. UNDER 1 YEAR 5C. UNDER 1 DAY 8. DATt_ OF BIRTH (MO., Day, Yr.)
<br /> (Y-s•) MOS. DAYS HOURS MINS.
<br /> Lincoln, Nebraska 55 February 19, 1954
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 507_74_95$5 HOSPITAL ^ Inpatient OTHER ®NurSing Home/LTC ^ HoepiCe Facility
<br /> 8b. FACILITY-NAME (H not Inatltution, glue street and number) ^ EWOutpatlent ^ Decedent's Hnma
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<br />Tiffany Square Care Center DOA Other (SPecHY)
<br />^ ^
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zlp Code- ed. COUNTY OF DEATH
<br />Ca Grand Island 88$03 Wall
<br /> 9a. RESIDENGE•STATE 9b. COUNTY 9c. CITY OR TOWN
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<br />z Nebraska Hall Grand Island
<br />7 9d. STREET AND NUMBER 9e. APT. NO. 9-. ZIP GODE 9g. INSIDE GITY LIMITS
<br />r 1011 Austin Ave. 68801 ®YES ^ No
<br />a 70a. MARITAL STATUS AT TIME QF DEATW ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />!E
<br />m ^ Married, but separated ^ Widowed ^ Divorced ©Unknown Pamela White
<br />b 11. FATHER'S-NAME (First, Middle, Laet, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />~ Maurice Sindelar Nadine Wondercheck
<br />°•
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service iF Yes. 14a. INFORMANT-NAME 144. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk.) NO Pamela Sindelar Wife
<br />,°'p 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />M ®Burial ^ Donation
<br />Tracey Dietz
<br />1328
<br />January 2
<br />2010
<br /> ,
<br /> ^ Crematipn ^ Entombment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> [] Removal ^ Other (Specify)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU E F DEATW ae instructions and exam les
<br /> 18. PART I. En[ar the chain of events--diseases, In)unea, or compllcatlonadhat dlnctly nuaad [he death. DO NOT enter terminal events such as caMlac arrest, I APPROXIMATE INTERVAL
<br /> resplratary arrest, or ventricular flbdllatlon wl[heut ahowlny the etiology. DO NOT ABBREVIATE. Enter only one Cause on a Ilne. Add additional Ilnas If naceasvry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE IFIhaI a) METASTASIZED PANCREATIC CANCER 2 MONTHS
<br /> disease yr cvndhlon resulting
<br /> In death) DUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> Saquentlally IIM wnditlons, If t))
<br /> any, leading to the cause listed
<br /> on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE O~
<br /> (disseta or Injury that Infllated
<br /> the events rosulting In death) DUE TO, OR AS A CONSEOUENCE OF: ~ onset to death
<br /> usT d)
<br /> 18, PART IL OTWER SIGNIFICANT CONDITIONS•Gonditlons contributing to the death but not resulting in the underlying cause given In PART 1. 19. WAS MEDIGAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~
<br />~ 20. IF FEMALE: 21a. MANNER OF DEATH 216. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Nat prognant wlthln pact year ®Natural ^ Homicide ^ OriverlOgeralor ^ yES ® NO
<br />U ^ Pregnant at time Of death ^ Accident ^ Pending Invastlga[lon ^ Passenger
<br />
<br />~+ ^ Not prognant, bul pregnant wlthln 42 days of death
<br />^ Sulclda ^ Could not bs determined ^ PeaenAan 21d. WERE AU70PSY FINDINGS AVAILABLE
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<br />^ Not pregnant, but pregnant 43 days t0 1 year belore death
<br />^ Other (Specify) O
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<br />AU
<br />E OF DEATH?
<br />a
<br />~ ^Unknown If pregnant wlthln the past year ^YES ^ NO
<br />
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<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22C. PLACE OF INJURY-At home, farm, street, faCtOry, efflCe building, COI1strUCtlOn Bite, BtC. (Specify)
<br />a
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<br />~S' 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />.
<br />.
<br />. 24a.~1ATE SIGHED_(Ma, DayrYc.~ - 7Mlripi p6ATH- - ' -
<br /> ~ ~ December 29, 2009 $ ~ ~
<br /> T 28b. DATE SIGNED (Mo., Day, Yr.) 2Sc. TIME DF DEATH ~ ~ K ~ 24c. PRONOUNCEb DEAD (Ma., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> E ~ z December 31, 2009 11:37 AM E ` _
<br /> ~ J O 3d. To the boat of my knowledge, death occurred at the tines, date and place
<br />$ ~ and due to the causele) stated
<br />(Si
<br />nature and Title) s W ~ O
<br />~ = p Yoe. On the heals Bf examinadon andlvr Investigatlvn, In my opinion death occurred at
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<br /> ~ Steven Husen, MD g a
<br /> 25. DID Tg8AGC0 USE CONTRIBUTE TO TWI: DEATH? 28a. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED9
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®Np Not Applicable K 26a Is NO ^YES ^ NO
<br /> (P ypa or r nt
<br /> Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 88803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (MO•, Day, Yr.)
<br /> January 6, 2010
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