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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAtTN AIUD KlI1�AN.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR�ISKA.DFPAR,�r1ENT QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vl��L ��ibl�D�S � �
<br />DATE OF ISSUANCE 2 0 9.10 ��" 9 �/.���Q��� y �' ,� �.+ �
<br />�.'°�
<br />01/26/2011 sraN�'�u s coo��R ,
<br />.�sSr�-ra�vr�r��� �5rfra�,',. ,�
<br />DEP.aRT`MEIil�''r0�'�-l�AL7'H ��1tD ' �
<br />LiNCOLN, NEBRASKA HUMA� �ERVICE� - -.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN $ERVICES;� •.'��� ` E+ �' `��' 11 002D0
<br />CERTIFICATE OF DEATH �', , �.��� ,r,-''_ , r_
<br />1. DECEDENTS-NAME (Fhst, Mlddle, Last, Sufflx) 2. SD( ;, �,�.�q�ATE �F pFATH{Mo., Day, Yr.)
<br />August Charles Retzlaff Male '`� ��anuary 21 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY , 6.. DAT� OF BIRTH (Mo., Day, Yr.)
<br />(�'►gd MO3. DAYS HOURS MIN5. ' = -
<br />Palmer, Nebraska 77 � March 22,1933
<br />7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br />506-32-8635 HOSPITAL � InpatleM O_ THER � Nurstng Home/LTC � Hosplce FacIIRy
<br />Sb. FACILIT'Y•NAME (If not Insqtutlon, give street attd number) � ER/OutpaUent ❑ Decedent's Home
<br />�
<br />� TlfFany Square Care Center ❑ DOA ❑ aner �speciry�
<br />� 8c. CITY OR TOWN OF DEATH {Include 21p Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� ea. RESIDENCESTATE eb. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AWD NUMBER 8e. APT. NO. 9L ZIP CODE 9g. INSIDE CIIY LIMITS
<br />� 215 Lakeside Dr. 68801 ❑ res � No
<br />� 7Ua. MARITAL STATUS AT TIME OF DEATH Married
<br />� � ❑ Never Married 70b. NAME OF SPOUSE (First, Middle, Last, Sufflx) If wife, glve malden mame
<br />€ ❑ Marrted, but separated ❑ Widowed ❑ Divo►ced ❑ Unknown �rO�yfl Wages
<br />d
<br />� 71. FATHER'S-NAME (First, Mlddie, Last, Suffix) 12. MOTHER'S•NAME (FUst, Middle, Malden Sumame)
<br />� Charles Retzlaff Emma Wegner
<br />°' 13. EVER IN U.S. ARMED FORCES? Giva dates W serWce ff Yes. 14a. INFORMANT 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� (ves, No, or unk.) Yes 04/22/1953-04109/1955 Carolyn Retzlaff W'rfe
<br />,$ 15. METHOD OF DISPOSI770N 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 76c. DATE (MO., Day, Yr.)
<br />F ❑ Burial ❑ DonaUon
<br />Not Embalmed January 22, 2011
<br />� Cremadon 0 ErnombmeM 18d. CEMETERY, CRENUITORY OR OTHER LOCATION CITY! TOWN STATE
<br />❑ Removal ❑ Other (Specffy)
<br />Central Nebraska CremaBon Services Gibbon Nebraska
<br />77a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Cky or Town, State) 17b.21p Code
<br />Greenway Funeral Home, 802 Templin, Palmer, Nebraska 68864
<br />CAUSE OF DEATH See instructions and exam les
<br />18. PART I. Fsmr the chaln ot eve�rte-diseasea, InJudes, or compucatlo�-that dlrecUy caused tha death. DO NOT e�rter terminal events auch ae cardlac errast, ; APpROXINUITE INTERVAL
<br />respiratory arrest, or vairtricular fibriiladon withcut ehowing the etlology. DO NOT ABBREVIATE. Fnter ony orre cause an a Iine. Add addidonal 16res It necessary. �
<br />IMMEDIATE CAUSE: � onset to death
<br />IMdIED1ATE CAUSE (Flnal a) Metasta�c Carcinoma Of The Prostate 6 4 Years
<br />dl�ase or condWon resuiting
<br />In tleattq W E TO, OR AS A CONSEQUENCE OF: ; orreet to death
<br />SequeMiatty Ilat candfdona, H b�
<br />em, ieaame w me �au� i�eca '
<br />on Itne a DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Frrterthe UNDERLYIN6 CAUSE C �
<br />(tll�ase or InJury that Initiated '
<br />��"�'�"�"� �" �� DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-CondiUons co�rtributing to the death but not resuiting In the undertying cause given in PART I. 18. WAS MEDICAL IXAMINER
<br />D'IBbeteS MeIIItUS, Typ@ II Hypothyroidism OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />17.
<br />� � NoSpregnaM within past yaer � � Naturat � Homldde �� DrfvedOperator
<br />❑ YES � NO
<br />U � PreBnarrt et Hme of death � AccideM � Pendln9 Inveetl8atlon ❑ Passen98r
<br />� � Not pregna�R, but pregnant withln 42 days ot tleath � aeueatrian 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />a � NM pregnarrt, but pragna�rt 43 daye to'1 year before death ����a ❑ COUId not be determlired ❑ �S�ci�� TO COMPLETE CAUSE OF DEATH7
<br />d
<br />'� ❑ UnlmownitP�enartwtth�nthepastyee� ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PIACE OF INJURY-At home, farm, street, factory, oftice buitding, car�truction a(te, etc. (Specify)
<br />E
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�'" ❑ YES ❑ NO
<br />221'. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH {Mo„ Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � January 21, 2011 ,� � �
<br />��} 23b. DATE SIGNED (Mo, Day, Yr.) 23c. TIME OF DEATH �� k Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ o Janua 21, 2011 09:25 AM � y<-'
<br />� 9d. To the best of my Imowletlge, death occurtad at the Ume, date antl place $��� 24e. On the basis oT exandnatlon and/or inveatigadon, In my opinlon death occurred at
<br />� 8 � a�e m ure �a�le� �ama. �s�e�mw�e ana rn�� 8 � ttre nme, date antl place and dua to the cause�s) stated. (Signature and Tttle)
<br />� William Landis, MD '' � ;
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 Z6b. WAS CONSENT GRANTED?
<br />❑ YES � NO � PROBABLY ❑ UNIQJOWN � YES � NO NotApplicable H28a Is NO � YES ❑ NO
<br />2. NAME, TITLE AND ADDRE TIFIE (P 1 , Y ISTANT, CORO ER S PHYSIC O UNTY OF2 (Type or PdM)
<br />William Landis, MD, 2444 W. FaidleyAvenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />January 24, 2011
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