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<br />STATE OF NEBRASKA � �; �
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE IVEBRASKA DEPARTMENT OF H�'AL, ���RUZCE$, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE`¢R�4,�K��,��PA,R, �'M�I��'; (3f� $IE'AI,TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS TNE LEGAL DEPOSITORY'F,(`J���')A'�,•IRE�qft�S �,: � �,
<br />� �1 �
<br />DATE OF ISSUANCE
<br />� `a� , '
<br />���'Aru��1's c�oP�°R ��� ; , C ; �`
<br />12/31/2009 � � � �. a � � �� � tls��s*AtvT,s��'��`.�.��T�R -
<br />� ��'pARTN1L�NT l��'aV-��'�(�7H /31Vp , ,:
<br />LINCOLN, NEBRASKA H����'��������' ' '
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEA4TH AND HUMqN S�RNIG�S" •s` , r '��� � µ 4 f '
<br />CERTIFICATE OF DEATH' , � �� �' � �' � "� �` t s ss�,�'�;. � � . . �' 09 03067
<br />1� DECEDENT3-NAME (Flrst, Middle, Last, Suffbc} 2: SEX `'^ 3; DATE OF DEATH (Mo., Day, Yr.)
<br />Richard Raymond Alexander Male December 24, 2009
<br />4.'GITY AND STATE OR TERRITORY, OR FORFJGN COUNTRY OF BIRTH Sa. AGE • Wst Birthday b. UNDER 1 YEAR Sc. UNDER 1 pAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs•) MOS. DAYS HOURS MINS.
<br />i Grand lsland, Nebraska 70 August 14, 1939
<br />7: SOCIAL SECURITY NUMBER 8a. PLACE OF pEATH
<br />5Q6--0�2-4488 HOSPfTAL � InpafleM' pTHER a Nurs(ng HomeILTC � Hospice Facllity
<br />8b. FACILITY•idAAAE (N not Institutlon, gWe street and number) � ER/OutpaUortt ❑ Pecederrt's Home
<br />�
<br />° Saint Francis Medical Center ❑ DOA ❑ Other (Speclfy)
<br />� S�',. CITY OR TOWN OF DEATH pnclude 2�p Code} Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9�, RESIDENCE-STATE ' 8b. COUNTY 8C. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 9d. STREET 1WD NUMBER 9e. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY LIMITS
<br />�, ' 19 Chantilly Street 68803 � rES ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffbc) ff wffe, gMe matde� �ame
<br />� � Q Marrled, but separated ❑ Wldowed ❑ Divorced ❑ Unknown {�areen Connie Peterson
<br />� 11'. FATHER'S-NAME (Flrst, Mtddle, Last, Sufflx) 12. MOTHER'S•NAME (Flrst, Middte, Maiden Sumame)
<br />d 'John Raymond Alexander Hazel Irene Scheibe
<br />�' 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. iNFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� I�res, No, or untc.) No Kareen Connie Ale�nder Wife
<br />,� 15, METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICEN5E NO. 18c. DATE (Mo, Day, Yr.)
<br />� � eur�a� ❑ normnon Danlel D Naranjo 1071 December 29, 2009
<br />❑ C�ematlon Q Entombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specif�
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Isiand, Nebraska 68801
<br />8, pART I. Enter the chaln oi eveM� dlseasea, InjuNee, or complicaqonsdhat dlrectly causetl the death. DO NOT eirter terminal eveMS such as cardiac arreat,
<br />resplratory artest, or vemricular Bbriliaflon without ahowing the edology. DO NOT ABBREVIATE E�rter only one cause on a Iine. Atltl additlo�l Ilnes H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Flnal a) Chronic Obstructive Pulmonary Disease
<br />dls°..ae 3 or c¢�diNUn resvkiny -
<br />In tleath) DUE TO, OR AS A CONSEQUENCE OF:
<br />Seiquentlally Iist condkipns, �r b) Pneumonia
<br />amr. leadtng ta the wusa Ilsted
<br />on Iine a DUE TQ, OR AS A COMSEQUENCE OF:
<br />E�rter the UNOERLYING CAt1SE ��
<br />(diaease or lnjury that Initlated
<br />th8 evente resultln8 in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LABT d)
<br />APPROXIMATE INTERVi1t.
<br />o�et 10 aeath
<br />Years
<br />anset to death
<br />2 Weeks
<br />onset to death
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS-CondiUons conMbuting to the death hut rrot resulU�g in tha undariylag cause gben in PART I. 19. WAS MEDICAL EXAMINER
<br />D9pression OR CORONER CONTACTED?
<br />❑ YES � NO
<br />� 20. IF FEMALE: 21a. MANOJER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not pre8na�rt within past year � Netural � Hom�clde � DrlvedOperator ��S � NO
<br />� Q PteB�M at 8me of death � pccide�rt � Pentling imead8atlon ❑ Pes�nger
<br />Q Not preenant. 6ut pregnant wNhtn 42 daye ot death � PedeaWan 21d. WERE AUTOPSY flNDINGS AVAILA
<br />� � swcme � Cowu not be determ�neu TO COMPLETE CAUSE OF DEATH?
<br />� � NM Pre9naM, but pregnaM 43 deYe to 1 year before death � Other lSDedh)
<br />d
<br />Q Unknown If pregna�rt wfthin the peat year ❑ YES ❑ NO
<br />E 22a, DATE OF INJURY (Mq., Day, Yr.) 22b. TIME OF INJURY x2c. PLACE OF INJURY•At home, farm, sVeat, factory, oftice building, constructlon site, etc. (Specify)
<br />�
<br />.S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�-
<br />❑ ves ❑ NO
<br />22f. LOCATIOId OF INJURY - STREET 8 NUMBER, APT.NO. CITYITOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.) �
<br />,� � December 24, 2009 .� �
<br />� } 29h. n!?TE StcNED (n.4�.. `F�: _ �3e. aune ns�cqru -_ _ - � � � >
<br />E�$ December 30, 2009 03:30 PM E N� o
<br />$� � a3d. To the best of my knowled8e, tleath occurred at the Uma. da�a and P�� $ �w
<br />� and due W the ceuse(s) stated. (Signature and Tkie) �� o
<br />~ a Thomas Wemer, MD ~ g s
<br />STATE ZJP CODE
<br />. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />���3RlL'u�ySEgnew.-�L+`p!��.�aj,vs �•'e4.-TI"l�n.°.�T�:�3Luu�tDG)E110 --
<br />On the basie ote�wminatlon and/or Imeatigatlon, in my opinlon death oceurted aL
<br />the tl�, date and place end due to tlta cauae(s) etated. (Signahire and TMIe)
<br />� YES ❑ NO ❑ PROBABIY ❑ UNKNOWN , � YES U NO
<br />I�AME, TITLE� RE CERTIFIER (i' YSIC HYSIC�V /6SSl§TAN4, CORO �� PHl
<br />Thomas Wemer, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />. REGISTRAR S SfGNATURE � _
<br />i
<br />Not Appllpble H 28a Is NO ❑ YES � NO
<br />28b. DATE FILED BY REGISTRAR (Mo.,
<br />December 30, 2009
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