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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES TH� RAIS�D SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND,, M<4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF TNE ORIGINAL R�'CORD ON FILE WITH THE NEBRASKAI7E�`PA�TM�I'7� �F H,�AI.TH AND
<br />HUMAN SERVtCES, VITAL RECORDS OFFICE, WHICH IS TPIE LEGAL DEPOSITORY FOR VI�(L l�KifJ�f�'D5 u� f `��
<br />DAT�E OF ISSUANCE ����� '�r�� . ` � , �
<br />06/29/2010 srAnr�.��Y s. coa��ie ` .
<br />2 o i o o s 7 9 s p�PqR ����� ��� g� �
<br />LINCOLN, NEBRASKA NUM�I�•SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT bF HEALTH AND HUMAN SERVICES '; ') O O'I 7J8
<br />CERTIFICATE OF DEATH - • • � - . -
<br />_ _... -- ..... ,.,.
<br />1. DECEDENT'$-NAME (FIrSf, Middl9, LaSt, Suffix) 2. SFJ( -,.� i9.iDATE QF��DEATFF'�MO., Day, Yr.)
<br />qscar Axel 5or enfrei Male June 22, 2010
<br />4. CITY AND 87AT� OR TERRITORY, qR FpREIGN COUNTRY OF BIRTH 5a. AGE - Laat 6lrthday b. UNpER 1 YEAR 5c. UNDER 1 DAY B. DATE OF BIR7N (Mo., Day, Yr.)
<br />(Y�' MOS. DAYS HOURS MINS.
<br />Grand Island, Nebraska 79 November 18, 1930
<br />7. SbCIAL SECURITY NUMBER 8a, PI.pCE OF DHATH
<br />50$-30-3430 H2SPITAL � Inpatlent OTHER Q Nursing HomalLTC � Hosplca Faclllty
<br />8b. FACILITY-NAME (If not Instltutlon, give sVeat end number) � ER/Qutpatient ❑ UeCadaM'B Homa
<br />K
<br />v 5aint Francis Medicai Carter C] �OA - Q Othar(Spaclty)
<br />� 9c. CITY OR TOWN OF DEATH (Includa Zlp Coda) Bd. COUNTY OF UEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER e. APT. NO. 9f. ZIP CO�E 9p. INSIDE CITY LIMITS
<br />� 417 E. 19th 5t. 68801 � YES ❑ Np
<br />� 10a. MARITAL STATUS AT TIME OF DEqTFI � Man�ed ❑ Naver Married 10G. NAME OF SPOUSE (Flrst, Mlddle, Last, SuHix) M wHe, pive maiden name
<br />d
<br />!E ❑ Marrled, 6ut separated ❑ Widowad ❑ �Ivorcad ❑ Unknown Harriet Fae 5chwieger
<br />`m
<br />� 11. FATHER'S•NAME (Flrst, Middle, Last, Sufflx) 12. MOTHER'S•NAME (Flrst, Mlddle, Malden Surname)
<br />Oscar' Sorgenfrei Mildred Petroldt
<br />4 1S. EVER IN U.S. ARMLI] FORCE37 Glva dates oi servlce H Yss, 14a. INFORNL4NT-NAME 14b. RELATIONSNIP 70 DECEDENT
<br />E
<br />$ �v.s, No, or Unk.) Yes 07/02/1951-06/11/1953 Harriet Sorgenfrei Wife
<br />� 15. METHOD OF DISPOSfTION 18a. EM6ALMERSIGNqTURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />F � 8urlal ❑ Donatlon
<br />Daniel D Naranjo 1071 June 28, 2010
<br />[] Cramatlon ❑ Errtom6ment 16d. CEMETERY, CREMATORY OR OTHER LOCATIpN CITY / TOWN STATE
<br />❑ Removal ❑ pthar (SpgcNy)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MqILING APPRESS (Street, City or Town, Sfate) 17b. Zlp Coda
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />A E F DEA H ee nstruct�ans and Bxam les
<br />10. PART 1. EMar tha cnain af owMa• •dlwaaaa, lnJurl�s, or compllcatlpna-that diroctly cau�ad d16 Awtll. �O NOT rMsrhrminsl sve�Na auGh as caM1aC arroat, ; AppROXIMATE IN7�RVAL
<br />Ye�pkatory artaft, or wMdcular tlbdllatlon wlthOUt shawlnq tM sHOlppy. pp NO7 ABBREVIATE. Enh� onty one puas an a Ilne. Add addklonel I�nes IT neCestary.
<br />IMMEDIATE CAlI3E: ; nnset to death
<br />IMMEPIATE CAUSE (Flnal a) Respiretory Failure ; 48 HOUrs
<br />: -.._ .
<br />.. '�iOYiNBFi6flAi�IGilYWii�l19- . . . ...._..._ "_. .. _.... . . . _-.. .... __- . . .-_ _'-
<br />� �' DUE Tp, OR liS A CONSEpUENCE OF: ; onset to death
<br />SaqwMlrlytldcondit�ona, b)Squamcus Cell Lung Cancer .. .. : 6 Months
<br />any, I9aAinp to thr cauw Iiotad
<br />on Iina a.
<br />�UE TO, OR A5 A CONSEQUENCE OF; : onset ta depth
<br />Er1WY thr IINOERLYINa CAUSE C �
<br />(dlawao or InJury that InIt1AMd
<br />tha avanq rosuklnp In dsath� DUH TO� OR AS A CON5EQUENCE OF: � onset to death
<br />usr d)
<br />18. PpRT II.OTHER SIGNIFICANT CONUITIONS-Conditlon� contributing to the death but not resultlna In tha underlying causa glven In PART I. 18. WAS MEDICAL EXAMINER
<br />Chronic Obstructive Ling Disease ,pneumonia,dementia OR CORONER CONTACTED?
<br />� � YES � NO
<br />W 20. IF F�MALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not pregnant wlthin paat yrar � Natupl � F1om�Cida � DAvsdOperator � YE� � NO
<br />U � Pro9n�Rt al tima oi OeAth � pcCIAaM � Pandln9 Invaatl9atlon Q Paexnper
<br />� Nae propnant, eut nreonant wknin as days or daath � Prdaalrlan 21d. W�ItE AUTOPSY FINQINGS AVAILABLE
<br />� .. � sulclde � CoulA not ba dWrrminod TO COMPLETE CAUSE pF DEATH?
<br />� � Not pnqnant, but prcqnant 49 daya to 1 year qgfpre death � OthrY (SpaGy)
<br />� � Unknown IT prepnant within tha paat yaar ❑ YHS ❑ NO
<br />°' x2a. DATE OF INJIIRY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURV•At home, Tarm, streat, factory, ottice bullding, constructlon slte, etc. ($peclTy)
<br />�
<br />s
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURREb
<br />O
<br />� ❑ YES Q NQ
<br />Yxf. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY(fOWN $TAT� ZIP COC1E
<br />2Sa. DATE pF DEATH (MO., D9;, Yr,) 24d. OA7E $IGNHI) (MO., day, Yr.) 246. 71ME OF DEATH
<br />� W June 22, 2010 � � �
<br />�� Y 23p. DATE 31GNED (Mo., Day, Yr.) 23c. TIME OF DEATH ���� 24c. PRONOUNCEQ OEAD (Mo., Uay, Yr.) 24d. TIME PRpNOUHCED DEAD
<br />� �= June 24, 2010 11:59 PM � �
<br />� 9d. To ths 4aM of my knOwledpa, Oaat11 oCCUYreA et thr timr, datr and place $��1� o p�y, On thr Wala af exsminatlqn and/p� Invastlgatlon, In my opinlon tlaath occurred at
<br />_ 8 ..__ ...... and dus W tha caussl�) atatad. (Sipnaturo ana Tnla) � Z� ths tlme, date and placa antl aue to tnr cauw�s) afatad. (5lynaturo and Tltlel
<br />'" Ryan D. Crouch, DO --- . . _ � g_g . _ . ... _ . _ _._ _-- - . - ._
<br />8
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. NA$ ORGAN OR TISSUE DONATION BEEN CONSIUEREp7 ZBb. WAS CONSENT GRANTED?
<br />� YES ❑ NO ❑ PR08AB4Y ❑ UNKNOWN ❑ YES � NO Not Appllcable If 28a Is N4 (] YES ❑ NO
<br />. NAM , I L , 1 I N ype or r
<br />Ryan D, Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28h. DATE FILED BY I��GISTRAR (Mq, Day, Yr.)
<br />June 25, 2010
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