|
- . STAT� OF. NEBRASKA
<br />. . �:. A i �� .�
<br />WHEN THIS COPY CARRIES THE RAISED SF.At OF THE NEBRASKA DEPARTMENi QP HEALTH AN ,H ,,,4 .'� '� �IFI�S .
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA�Q�PA`,R��� �. �;�, ���.� ;
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WH7CH IS THE LEGAL DEPOSITORY FOR I�T� -�I, L;� �.�' . , � J -. � 1 �t I _ ' �` :� �,
<br />� � J I\ i x A'1�-.:_" �� w�-�',�� . ..
<br />DATE OF IS5UANCE ��.. �� � � � �� ,
<br />�. �„
<br />Sl"i4�1lL-�"' � $ ,; s ,�• �'��,
<br />02/01 /2011 � � � ` x + f ��� ;� �; ' `
<br />2A�.1023�3
<br />, s��'�`� ,�t.� �$�"; �.
<br />s� , �
<br />LINCOLN, NEBRASKA' ' ����` z ..4 � *,;,✓�,' H,
<br />"t� �r Y� :� �
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH ANp FUMAN SF�R���"� ' ��� � �' • �'"ti � �',�";� �2$g, �
<br />CERTIFIGATE OF DEATH � :� ' �'�'' ' 2�.�'� , • .
<br />1. DECEDENT'S•NAM@ (Flnt, MkWle, Lask Suftix) 2, SRaS ���,�,� � (Mo. MY� Yr.)
<br />William Herman Dibbern le ��* �, ,�<�-J�nuary 26; 2011 '
<br />4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER:1 DAY • 6: DATE OF BI TH (Mo„ Oay, Yr.)
<br />(�'+Y•► MOS. DAYS ti0UR3 Mtt�. " � '
<br />Wood River, Nebraska 85 March 18, 1925
<br />7. SOCIAL SECURITY NUMBER E�. PLACE OF DEA'!N
<br />508 H4$P.1I96 ���aat�ent OTHER ❑ nursir� ►iwna��rc ❑ Hosace Facuny
<br />8b, FACIUTY•NAME (If not Inatltutlon, gfve sheet and numbe� ❑ ER/Outp�tlent ❑ becedern's Homs
<br />� Saint FranCis Medic�l Center ❑ ooa ❑ ah°r ls�'ec�ry) .
<br />W 8c. CITY OR TOWN OF DEATH pnclude ZIp Code) Sd. COUNTY OF DEATH . _ __-.. _.
<br />. b Grand Island 88803 Nwa11 " .
<br />� 9a. RE5IDENCESTATE 8b. CpUNTY 8c. CItY OR TOWN ,
<br />w Nebraska HaH Wood River
<br />LL 8d. S'CREET AND NUMBER . ApT. NO. 9f. ZIP C� 9p. INSILIE CITY LIMITS
<br />1401 East St. 68883 ❑ vES � No
<br />.$ 10a. MARITAL STATUS AT TlME OF DEATH Q Ms»9ed [] Never MarHed 10b. NAME OF SPOUSE (Flrst, Mlddla, last, �ffiz) M wKe, B�� ��deA mm!
<br />� ❑ nnaRioa, n�c $epe�,t�a p wna�.a ❑ Divorced ❑ Unknown Jo J Rathman
<br />d
<br />� 11. FATHER'S�WAME (First, MWdle, iasf, Sufflx) 12. MOTHER'S•NAME (First, �le, Malden Surnam�
<br />Herman H Dibbem Margaret E Holtford
<br />n 13. EVER IN U.S. ARMED FORCE3? GWe dates �serWCe If Yu. 94a. INFORMANT•NAME 14b. REIATICNSMN' TO DECEDlNT
<br />g �ras, No, or unk.> No Carrie Lo Dau hter
<br />$' 15. METHOD OF D13POSITION 76a. EMBALMER-SIf3NATURE 18b. LICENSE NO. 76c. QATE (Ma., Dry, Yr.)
<br />� � e���ai ❑ oo�twn Derek Apfel 4240 � January 31, �014
<br />❑ Crematiod � Entombment 16d. CEMETERY, t�R�MATORY OR OTHER LOCATION CITY I TOWN ' STASH
<br />❑ Removal C] Other (SpecNy)
<br />Berwick Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MNLINCi ADpRE88 (SVS�t, Cky or Town, State) 7Zb. Zip Coda
<br />Apfel Funeral Home, 1123 W. 2ncf, GrBnd Island, Nebraska 68801
<br />ns r ons an exam s
<br />. � 1!. PART I. EM9� the chaln o(gy�.dseaps, ir�urhr. a eomnneuionax�a� au.aiy ceus.d� un am�. oo rw�r.nwr am�iaai •vsna sucn as cudiac.mu,� � � 7....pPPROXIMATE� INTERVAL �. .
<br />� rospiratory amst, or wMi7c�ar �tlpqon witl�out ahowi�p tha atWlopy. 00 NOT ABBR8IMTE. Emw onty ona cause oA a Iins. Add atlOiGoml Uma 0 neceasery• � . - �
<br />FMMEDIATE CAUSE: ; Omet t0 dseth
<br />��neou� cnuse �Pmai a) Pneumonia ; 2 Weeks
<br />tlieaase or eondttlon resultMp � . . .
<br />M da�h� DUE TO, OR AS A CONSEQUENCE OF: � oro�t tp dssth
<br />SequaMiaUy Ilst condiNons, u b) Recurrent Aspirat(on : 7 Year
<br />anY. kadiny to the ca�sa Iis[wl � . � . . � . - � � � � �
<br />on Ilne a. DUE TQ OR AS A CONSEQ ENCE OF: � oMlt ta r
<br />� EM�r Nw UNDERLYIN6 CAUSE �l Alzheimers � � � � � � � � � ! 2 Ye�3 � � . . � .
<br />. . � (diwaa or Injury that Mttiated � . . . . . . . . . .. . -.�_
<br />. M� ewnp nsukMp M Math) DUE TO� OR A3 A CONSEQUENCE OF: � � �� �� � ons�t to dapth . ��
<br />LAST d) � � � �. . � .
<br />19. PART II.OTHER SIC,NIFICANT CONDITiONS�CaitltUO� co�rlbutinp to the deeth but not nsaiting In tho underlyfng cause gNen In PART L h9. WAS MEDIGAL EIUMIWER
<br />Non-Related Diebetes OR CORONER CONTACTED?
<br />� � YE9 ❑'NO
<br />W O. IF FEMAIE: 21a. MA►#NER OF DEATM 21b, IR TRANSPORTATtON INJUR 21c. WAS AN AUTOPSY PERfORN�D?
<br />� . � � Not prepnant within W+� Year . � � Natutat � . � MOmkids � DrIwMOM�ator � � � YB3 , . � �NO � � � � . :.
<br />� � PrepnaM at tirnrof tluth . . � .. � AcalOent . � P�rbinY ImesHY+tbo ❑ Paas�o9ar . . . � �. � .
<br />. � �NOtprepnaM,b4K�propnaMwlMln42drylOfMtth �P�tlesui�n 21d.WER@AUTOPSYFINWNC;S�AY . .
<br />� Suidda � CoWtl not w Aetennimd TO COMPLETE CAUBE OF Dl.ATH?
<br />� NM.prepnant, dut prepnaM N tlays W Y yNf Mtoro tleNh � . � Othsr (EpecNy)
<br />� � Unknown 7 PnYnmt wNhM �a Past Ywr ❑ YES � NO
<br />€ 22a. DAT! OF INJURY (Mo., Day, Yr.) 22b. TfME OF INJURY 22c. PLACE OF tNJURY•At fwme, farm, street, factory, oi(ice bulWMp, consNuetbh sits, qtc. (8p�ciy)
<br />�
<br />S� 22d. INJURY AT WORK1 2e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�" ❑ YES ❑ NO
<br />22f. LOCATION OF FNJURY - STREET & NUM9fR, APT.NO. CITY/POWN STATE ZIP CODE
<br />29a. DATE OF DEATM (Mo., Day, Yr.) 24a. DqTE SIGMED (MO., Day�Yr.�. ••= 246. TNNE OF OFATH �
<br />� � January 26, 2011 � _ . � � �
<br />� � r 23b. DATH SIGNED (AAo., Day, Yr.) 23C. TIME OP DEATH �} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIM@ PRONOUNCED DEAD
<br />�-+ Janua 28, 2011 12:39 PM ��<�
<br />� 3tl. To Ms best oi my knowlWp�, WNh oocurnd at M� tMa, qab�aad plaa �$��� qy, p� �rye Dasia of examinat(on aiM/or tnvwtipatton, in my opinion death occum0 at
<br />. �� �ntl dua W ths caute(� statad. j�9natun m0 TfGq) . o � . - the tlme� d�te and p�aa And dw u 1fia autelfl rtaMA. (ll��n and Tld�p ... ;
<br />~� Gary Settje, MD ,. �� r a
<br />25. Diq TOBACCO USE CON RIBU TO THE DEATH't 26a. ORGAN OR TISSUE DO TION EEN CONSIDERE 9 28b: WRS N
<br />YES � NO � PROBABLY ❑ UNKNOWN � YE3 � NO ' Not Applieable M Z6a is NO YES NO :
<br />r YP �►
<br />�(3ary Settje, MD, 2116 W Faidiey #4Q0, Box 9802, Grand Island, Alebraska, 68803
<br />28a. REGISTRAR'3 St6NATURE 20b. DATE FILED BY REfi1STRAR (Mo., Day, YrJ
<br />January 31, 2011
<br />Exhibit '�A�� ,
<br />
|