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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT.k)'AIN0'/,1 VICfS IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAICl~;;PArtjytTaQ 11fE4CTH AND,
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOIE: V. gL.1917 Ir
<br /> DATE OF ISSUANCE /t *1~0.
<br /> ~Tq~1L~r
<br /> LIAR o 2 zolo 201008755 A$3aAN~TPFSTRA
<br /> DfPA 7'MENr_ f h~ ~~uo FIjEEXHIBIT
<br /> LINCOLN, NEBRASKA H6 14 S A
<br /> STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES ,
<br /> ~e
<br /> CERBEICATE OF DEATH
<br /> 1. DECEDENTS-NAME (First, Middle, Last, Suffix) 2 SEX 3. DATE 00 DEATW lIk%,D4y,Yr.)
<br /> Fred Edward Rauert Male February 23, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 64, A012-Lost Birthday 8b. UNDER 1 YEAR ft UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS PINS.
<br /> Grand Island, Nebraska 86 April 13, 1913
<br /> 7. SOCIAL SECURITY NUMBER a•. PLACE OF DEATH
<br /> 5507-48_6342 HOSEITAL: ❑ Inpatient OTHER, D9 Nursing HonMILTC ❑ Hospice Facility
<br /> 8b. FACILITY-NAME (H not institution, give street and number) ❑ ERIoutpatient ❑ Decedent's Home
<br /> Hamilton Manor ❑ ODA ❑odwaspwfy)
<br /> Be. CITY OR TOWN OF DEATH (Include 21p Coda) ad. COUNTY OF DEATH
<br /> Aurora 68818 Hamilton
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hamilton Aurora
<br /> 9d. STREET AND NUMBER 9a. APT. NO. 9r. ZIP CODE, 4 INSIDE Crrir Lams
<br /> 1515 5th St. 68818 ~tJ Yea ❑ No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married lob. NAME OF SPOUSE (First, Middle, Lest, Suffix) H wife, give maiden name.
<br /> e~ Married, but separated ® Widowed Divorced ❑ Unknown
<br /> m
<br /> E 11. FATHER'S-NAME (First, Middle, Last Suffix) 12. MOTHER'&NAME (First, Middle, Maiden Surname)
<br /> 0 August Rauert Martha Boldt
<br /> Go I& EVER IN U.B. ARMED FORC937 Give dates of service H Yes, 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> F
<br /> (Yee, No, or Unk) NO Glenn Rauert Son
<br /> 1& METHOD OF DISPOSITION Asa. EMBA R [ON URE~ lab, LICENSE NO. 180• DATE (Mo., Day, Yr.) -
<br /> IN Burial ❑DOMIlon 1. • /Z ~O Februa 27, 2010
<br /> ❑craoation ❑EMorntnwM
<br /> ❑n.mm.l [~gimer(gpksy) 78d, CEMETERY, CREMATOR • OR OTHER LOCATION CITY/TOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17m. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City or Town, State) 17b. Zip Coda
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> CAUSE OF 0=0T Instructions and exam lee
<br /> 18. PART 1. Prow th. Chad orw hr . distam" Injuda-, or comps-ams. NMI dkaaar enur temudu evenl--uch ar caN' unet i APPROXIMATE INTERVAL
<br /> m.pir dory amask or ventricular nbdtladon Without ahomoll U* 0111 logy, DO NOT AaBREVIATIL Ewer only an- muse on a 1155. Add additional sews If rem may.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final y
<br /> disease or condition resulting a) C I_A
<br /> 'V'VU`"""'"-,
<br /> In death) CA'V(-) C ~ U ~ a, a,
<br /> DUE TO, OR AS A CONSEQUENCE F: ; onset to death
<br /> Sequentially list conditions. If
<br /> b)
<br /> any, leading to the cause listed
<br /> on line & DUE TO, OR AS A CONSEQUENCE OF: onset to doom
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or Injury that Initiated
<br /> the wants resulting In death) DUE TO, OR AS A CONSEQUENCE OF: Driest W daseh
<br /> LAST
<br /> d)
<br /> 19. PART U. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not rswaurp In ft underlying cause given in PART L 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ❑ YES W NO
<br /> W 20. IF FEMALE: 21a. MANNER OF DEATH 2lb. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> LL
<br />
<br /> ❑ Not pregnant within past year Natural ❑ Homicide ❑ DdvedOparimtar ❑ YES J~atO
<br /> W ❑ Pregnant at time of death ❑ Accident ❑ Pending Investigation Passenger 2111. WERE AUTOPSY FINDINGS AVAILABLE
<br /> fJ ❑ Not pregnant but pregnant within 42 days of death ❑ Suicide ❑ Could not be determined ❑ pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> a ❑ Not pregnant qui pregnant 43 days to 1 year before death ❑ Other (Specify) ❑ YES ❑ NO
<br /> ❑Unknown It pregnant within the
<br /> peal year
<br /> a
<br /> 3.
<br /> 0 222. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY 22c, PLACE OF INJURY-At home, farm, street factory, Office building, construction site, air- (Specify)
<br /> U m
<br /> m
<br /> m 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br /> YES ❑ NO
<br /> 22f. LOCATION OF INJURY - STREET A NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH M Day, Yr Z 24s. DATE SIGNED (Mo,, Day, Yr.) 24b. TIME OF DEATH
<br /> l~ .9 0 m
<br /> U 23b. DATE SIGNED Mme., paYr.) 23c. TIME OF TH m
<br /> -0 65 i :0-
<br /> S 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> E VL -1
<br /> o //~I~ 'u\ E w = m
<br /> d U 2311. To the peat ar knowledge, d alithl and at the time, date and place 3 240. On the basis of examination and/or investigation, In my opinion death occurred
<br /> O W and due to .cause(s) stated. ( g atu end This)
<br /> .91 7 at the time, date and pieta and titre to the cause(s) stated. (Signature and Tlge)
<br /> 26. DID TOBACCO USE CONTRIBUTE TO TH FATH? 241a. HAS ORGAN OR 718SUE DONATION BEEN CONSIDERED? 29b, WAS CONSENT GRANTED?
<br /> YES iANO ❑ PROBABLY UNKNOWN ❑ YES I NO Not Applicable If 26a Is NO ❑ YES []NO
<br /> 27, NAME, LE AND ADDRES OF ~I~ RTIFIER (PHYSICIAN, PHYSICIAN ASST TANT, C¢RONEII'S PH1 CIAN OR C LINTY ATTORNEY) (Type or Prim)
<br /> 28& REGISTRAR'S SIGNATURE 26b, DATE FILED Y RFAISTRAR (Ma., Day, Yr.)
<br /> .U FEB 2 6 ~a1n
<br />
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