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<br />STATE OF NEBRASKA J
<br />WNEN THIS C�PY CARRIES THE RAISED SEAL OF THE NEBR.45KA DEPARTMENT OF MEAL�"ld,�V�'k!�l,M�1N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON F�IL� W1TH 7'NE IVEBRa9'�K.A,CJEP.AF�T,lN�NT OF HEALTH AND
<br />HUMAN SERVICES, VITAL R�CaRDS OFFIC� WHICH IS THE LEGAL DEPOSITORY FQ,�t" Vr�`,�FL: F�ECQRDS '
<br />.T " � �'� �'
<br />DATE OF ISSUANCE � � � ���
<br />02/24/2010 z o i o 0 7 s 3� ����� �-�Q� R�zs���
<br />" C3��fX�Z7' � l{I-P dF�{-1�LTH .4NG�''
<br />LINCOLN, NEBF2ASKA �,1�j,NFA�( q ��I�VI�ES.; � "
<br />� I' h'' �./ ' � e � "
<br />STATE QF NEBRASKA - DEPARTMHNT OF HEALTN AND HUMAN �RWC���� ���;"�- ,;� � s �� OO4T�
<br />\rCRI lf IVA1 G VP UGAI l'7 � �����• "-
<br />1. U�CEDEN7'S-NAME (Flrsy Mlddle, Last, Sufflx) 2. SEX` 6�„ " 3:`•DATE OF ATH (Mo., Day, Yr.)
<br />William A Rauart Male �' - ,Fsbruary 14, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. AGE • Last Birthday h. UNUER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH �Mo., Day, Yr.)
<br />(Yrs•) MPS. DAY$ NOURS MINS.
<br />Grand Island, Nebraska 79 February 6, 1931
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATM
<br />508-46-7069 bQ§�17AL Q Inpatlent OTIIER ❑ Nursing Homa/LTC Q Hospice Facfllty
<br />Sb. FACILITY-NAME (N not Insdtutlon, qiva streat and numbar) .� ER/Outpatlqnt � Decedent's Home
<br />K
<br />DOA Othar (Speciy)
<br />� 4450 N. Engleman Road ❑ ,❑
<br />� Bc. CITY OR TOWN OF nEATH Qncluda Zlp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 88803 Hall
<br />� 9a. RESIDENCE•STATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />z
<br />LL 8d. STRE@T AND NUMBER 9e. APT. NO. 9f. ZIP COpE 9g. IN$IDE GTY 41MITS
<br />� 4450 N. En leman Road 68803 ❑ v�s � No
<br />� 10a. MARITAL S7A7uS A7 TIME OF D�A7H � Manlad ❑ Never Marrled 10b. NAME OF SPOUSE (First, Mlddle, Last, Su(fix) H wlfa, glva maiden name
<br />� ❑ M.rrled, but separated ❑ Widowed ❑ Divorced ❑ Unknown Audrey g2��
<br />m
<br />� 11. FATMER'S-NAME (First, Mlddle, Last, Suffix) 12. MqTH�R'S-NAME (Flrst, Mlddle, Maidan Surname)
<br />� Arnold Rauert Minnie Niemoth
<br />$' 18. EVER IN U.$. ARMEO FORCEST Give date: pf servlCe If Yes. 74a. INFORMANT-NAME 146. RELATION3HIP TO DECEDENT
<br />E
<br />q �ves, No, or unk.► No Audre Rauert Wife
<br />� 15. METHOD OF pISpOSIT10N 18a. EMBALMERti51GNATURE 18b. LICENSE ND. 16c. OATE (Mp., �ay, Yr.)
<br />w � Burial ❑ Donatlon
<br />Chris McCoy 1191 February 22, 2010
<br />[J Crematlon Q EntO�llbrtlBrlt �Bd. CEMETERY, GREMATQRY OR OTHER LQCATION CITY / TpWN STA7E
<br />❑ Removal ❑ Other (SpeclTy)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINC3 A��RESS (Street, City or Town, Stata) 17b. Zlp Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />D AT es instructipns an exam les
<br />18. PART I. Entar [ha chaln of flvents--dlsaasas, InJuries, Or compllcatlona-that dlrectly causad tha death. DO NOT onhr Ierminsl eventa sYCh ag cardiac arroat, ; APpROXIMATE INTERVAL
<br />reapintary arroat, or venMcular fl6rlllatlon wl(hout ahowlnp thr YtlabQy. DO NOT A88REVIATE. Enlar only pne causa an a Iing. Add addltlonal Ilnrs If nacaqary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Flnal a) Sudden Fatal Cardiac Arrhythmias ; Minutes
<br />Alwat! or condRlon re�uldnp
<br />In death� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />8equantlatty Ilst condltlons, If b) Extensive Calcified Old Myocardial Infarction : Months
<br />any, Isadlnp to tha cau�e I�aed
<br />on nne a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />EnM�thB UNDERLYING CAUSE �) Severe OCGlusive Calcific COronary Artery Disease : Years
<br />(tlltaAeb o� InJury that InttfitaG
<br />the ovantt relultinp In drath) DUE TO, OR AS A CONSEOUENCE OF: : onset to death
<br />LAST d)
<br />18. PART 11. OTH�R SIGNIFICANT CONDI710N5-Condltions contrl6uting to tha death 6ut not rasultlnq In the underlylnp cause plvan In PART I. 19. WAS MEDICAL EXAMINER
<br />Bilateral Pulmonary Emphysema And Cardiac Cirrhosis dR CORpNER CONTACTED7
<br />�
<br />� ves ❑ No
<br />� 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not prrqnant wlthln pyat yea� � Natural � HomlClda � pdvsdOpsrator � YES ❑ NO
<br />U Q Prepnant at tlme ot death � Accident � PYndinp InveStlpapon Q Paqanpar
<br />� Nm prepnant, nut prepnant wimin az days at deatn gWC�tla CpYld npt ba datprmin9d ❑ P���Yien 21d. WERE AU70PSY FINDINGS AVAILABLE
<br />� � Not prvqnant, bW proqnant �3 daya to 7 yoar bitore Aaet6 � � � an.r �sa•cirvl 70 COMPLETE CAUSE OF pFJ►TF17
<br />� � �nknown If pnpnpnl wtthin the past yaa� � YE5 Q NO
<br />� 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME pF INJURY 22C. PLAGE OF INJURY•At home, fal'm, strest, TaCtory, oiflce bullding, constructlon slte, etc. (SpeclTy)
<br />E
<br />0
<br />u
<br />S� 22d. INJURY AT WORK7 22e. DESCRI9E HpW INJURY QCCURRED
<br />0
<br />� ❑ v�s ❑ No
<br />Z�1. LOCATION OF INJURY - 5TREET 8 NUMeER, APT.Np. CITYlTOWN $TATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr,) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />_ _ _ E� �. _ _ .. __.. 3� � � Pebruary 17, 2010 02:41 PM
<br />� �� 236. DAT� $IGNED (Mp., Day, Yr.) 23c. 71ME OF DEATH ��` J 24c. PRONOUNCED �EAD (Mo., Day, YrJ 24d. TIME PRONOUNCED DEA�
<br />}� Februa 14, 2p10 02:41 PM
<br />$�� 9d. To the best of my knowladqe, death occurcsd at tha time, data and place ���� 2qa, On tne bas�a of axeminapon andior Investlpatlon, in my opinton death occurred at
<br />g a antl due ro tha cau�e�s) stataA. (Sipnaturo and Title) g p �he tlma, date and placa and dur ta tha cauw(s) atatrd. (Slynatura and Tltle)
<br />~� "�; Matthias I Okoye, MD J�
<br />25. DID TOBACCO USE CONTRIBUTE TO TME DEATH� Y6a. HAS ORGAN OR TI5SUE UONATION BEEN CONSIDERED7 28b. WAS CONSENT (iRANTEP?
<br />❑ YE$ � NO ❑ PRQeABLY ❑ UNKNOWN ❑ YES � NO Not Appllca6la It 26a Ia NO Q YES ❑ NO
<br />. ypa or r n
<br />Matthias I Okoye, MD JD, 6940 Van Dorn Street, Ste 105, Lincoln, Nebraska, 68506
<br />28a. REGISTRAR'S 51(3NATURE 28b. OATE FIL.ED 9Y REGISTRqR (Mo., Day, Yr.)
<br />February 23, 2010
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