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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL QF THE NEBRASKA DEPARTMENT OF HEALTH ApLl~,HL>11~1y4r,11 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASr~~T 3E~,•~,T~ M.E/~l~ b~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR JQ7A, gV~CORDS.' - .,,. ) )
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<br />DATE OF ISSUANCE ~~/d, ~ ~ ~ l
<br />09/09/2010 sFAKI.~Y S. CO~ip~"k ••, t , ; ;
<br />2oioossss ~~~,~"~~~`~~o~~
<br />LINCOLN, NEBRASKA HUMtIN ;SERVICES '" ~ .- ,; a
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SEI~~(ICES ' • ' ~ ~; r~ r ~ ~'.. • , ,~. ~ ~ 0 02485
<br />CERTIFICATE OF DEATH " ` .',' ~ •' • .. -
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ~ v ; D
<br />,h DF DEA (MO., Pay, Yr.)
<br /> Dona Mae Landgraf Female ~' ~~ `' ,
<br />Septefr-ker 1, 2010
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br /> IYrs.) MOS. DAYS HOURS MINE.
<br /> Kansas City, Missouri 84 Ma 10, 1926
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 507-22-9986 HOSPITAL ^ Inpatlam 4TJiE8 ®Nursing HomelLTC ^ Hospice Facility
<br /> 8b. FACILITY•NAME (If not Instltutlon, gNe street and number) ~ ERlOufpatlettt ^ Decedent's Homa
<br />
<br /> Tiffany Square Care Center ^ DOA ^ Othsr (Specfy)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />5 Grand Island 68803 Hall
<br />J 8a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br />~ ed. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />~, 704 W. Ha a Ave. fi8801 ®YES ^ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) R wife, give maiden name
<br />!E
<br />d ^ Married, but separated ^ Widowed ^ pivorcad ^ Unknown Dr Charles Landgraf Jr
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Dr Leslie Johnson i2uth Zimmerle
<br />a
<br />E 1s. EVER IN U.S. ARMED FORCES? Give dates of service K Yas. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DEGEDENT
<br />$ (YSS, No, or unk.) No Dr Charles Land ref Jr Husband
<br /> 75. METHOp OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />H ^ Burial ^ Donation
<br />Not Embalmed
<br />September 2, 2010
<br /> ® Cremation ^ Entombment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Westlawn Memorial Park Crematory Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> Livingston-5ondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> A H ae instruct one an exam es
<br /> 78. PART 1. Enter the chain of aventi••diseawa, InJurles, Or Complicadons-that dlnctty aussd the death. DO NOT emer terminAl Buena such as cardiac arren, I APPROXIMATE INTERVAL
<br /> resplretDry arrea6 Or vemHCUlar phrlllnlon without showMp tlw nlology. DO NOT ABBREVIATE. Enter Only One cauq On A Ilse. Atltl atltlltlonal Ilnes If nviceswry.
<br /> IMMEDIATE CAUSE: orttet to death
<br /> IMMEDIATE CAUSE (Final al Cor Pulmonale :Weeks
<br /> alwase or contlniOn raaulnnp
<br /> In death) DUE TO, OR AS A CONSEQUENGE pF:
<br />pn5at to death
<br /> SBquentlNlly Ilst Conditlone, if b) Pulmonary Valve Insufficiency :Years
<br /> arty, Ieatling t0 the wup Ilsad
<br /> Dn Ilna a. DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (diaede9 or InJury loaf Innlatetl
<br /> the events resuning in aeatnl DUE TO, pR AS A CONSEQUENCE OF: t onset to death
<br /> LAST dl
<br /> 18. PART II.OTHER SIGNIFICANT CONOITIONS•Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> Congestive Heart Failure OR CORONER CONTACTED?
<br />~ ^YES ®NO
<br />w 0. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not prognant within past year ®Natural ^ Homicide ^ OflvedOpentar
<br />
<br />~
<br />^ Pregnant at um0 Of death
<br />^ AcCltlent ^ Pending Invud9allDn
<br />^ Paswngar ^YES ® NO
<br />
<br />~` ^ Not prognant, but prognant within 42 days of death
<br />^ Suicide ^ Couitl not lw dnermined ^ Pedeatdan 21d. WERE AUTOPSY FINDINGS AVAILAaLE
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<br />©NDt prognant, but grepnaM 4! days to 1 year below death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br />~ ^ Unknown 11 pregnant wkhin the pan year ^ YE$ ^ NO
<br />°' 22a. DATE OF INJURY IMo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, ofnce building, construction site, etc. (SpacHy)
<br />
<br /> 22d. INJURY AT WORK? 229. pESCRIBE HOW INJURY OCCURRED
<br />0
<br />t`
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 2Sa. DATE OF DEATH (Mo., Day, Yr.) 24a. PATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />Se
<br />t
<br />mber 1
<br />;
<br />2010
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<br /> 23b. DATE SIGNEp (Mo., Day, Yr.) 23c. TIME OF DFJ-7H ~ ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> J
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<br />E „ Z S® tember 2, 2010 10:10 PM E 4 ` ~
<br /> O 3tl. TO the lwn or my knowledge, death occurred at the time, date and place $ ~ G
<br />(Signature and TI[la) E z SM. On tlw basU of axaminatlDn andlOr InvaetlgatlDn, In my DpinlOn death occurred at
<br />anA Oue to the Cauca a stated
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<br /> .
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<br />e lima, date and place antl tlue to gle Causa(al stated. (Signature and Tttlel
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<br /> ~ Travis 5. Hageman, MD ~ a
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE pEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIpERED7 26b. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not AppllCabla ff 26a Is NO ^YES ^ NO
<br /> • A 1 ype or r nt
<br /> Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.-
<br /> September 7, 2010
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