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<br />�� STATE OP NEBRASKA ,� � � �'� � ,;;.
<br />WHEN 'THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT O� NEAL� ���I�I.SERVICE$, lT CERTIFIES
<br />THE B LOW TO BE A 7RtlE COPY OF TME ORIGIN,4L RECpRD ON FILE WITH.:THE Y,VE'BRAS}G�1" Q ��h,?�V�"�' HEACTH AND
<br />HUMA� SERVICES, VITAt RECORDS O�FFICE, WHICH IS THE LEGAL DEPOSITOR� Fd')R �1Ti�L�17ECORDS,� `�!-, � i� ' .,
<br />� r � �' "� �°+ E � t/ � � , ,� r � :' ., �
<br />DAT� O� ISSUANCE ' � � �"' �(� ; T ��, � � . ..
<br />"������� : � U �
<br />� '; r�+_ � `
<br />� S'�'.�4�1k'�".S COOPER 1 F ' �
<br />�SEP� 2 � �201� _ � ' � � ���,�,v���9�E r�rRa� �� �
<br />' p���m�'�'��4;at�t�,
<br />LIAICQLN, NEBS.AS _ _ H�l E4l1�SER1/1C�5'� �" ?�: .;'..� ;
<br />' _ , : � C� ., /"� � �;,�� 1 `r ; ' � � .:` �„ � ,,
<br />. � a �`t�' s .�;'� � � ` • ��1 �-� � ,
<br />, �':. �t J��`t�1�'� � .
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FlNANCE 11ND S��L'�T' "'
<br />CERTIFICATE OF DEATH ` -' � ,`� �
<br />�� � � �1.�DECEDENT'8-NAME (Firat, � � Mlddla, Le61, Sufflx) 2.SEX �'.���:DATEOF�EATH(Mo.,08y,Yr,)
<br />Ra ond., Dou las-, R1in enbes Male 5e t, 21 2010
<br />i + 4. CITY AN� BTATE ORTERRITOHY, pR FOHEIQN COUNTRY �F BIRTH 6a. AqE•Leat Birthday Bb. UNDER / YEAR 6a UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey. Yr.) '
<br />(Yra.) MOQ DAYS HOURB MINS.
<br />I �;``�� Brooklyn, New York 7g April 7, 1932
<br />� �'�; � ` �.sociusequarnriun�eea ' saw.aeEOFOeani
<br />„ : 087 HOSPITAL �nvanem � ❑nw�grom�r�TC_oeaoaW�e��may
<br />���., .
<br />r� Bb. FAO(LITY NAME (If nOt IneOtutlon, give etreat end number)
<br />� � O ERlOutpaHeM ❑ DeoedenYsHome
<br />�:` V. A. Hoapit�l Grand Island, NE. ❑ ur+ ❑om�rt�rl
<br />-. Bc.CITVORTOWidOFDEATH (InoludeLpCode) Bd.COUNTYOFDEATH
<br />; ,s; :`� Grand Islaad 688U3 Hall
<br />9aRE51DENCESTATE Bb.COUNiY � Bc.CITYOqTOWN.
<br />;�'"� Nebraska 'Hall Grand Island
<br />��' ' sa:sr�r�rroNUr��
<br />; , Be.APT.NO 8f.7JPCODE Bg.INSIDECITYLIMITB
<br />''.'� .;; 2907 Hancock Place 68803 D rea ❑ No
<br />`_ :
<br />�u s�� tOfl: MARRAL STATUSAtTIME OF DEATH �Msrrled ONever Menled tOb. NAME OF 9POUSE (Flrat, Mldtl�e, Lest, 9uHiq It wl}e, give malden name, �
<br />sk �r. _ . . . .. .
<br />�� ,� r 0 Married, but separat6d O Widowed ❑ Divorced ❑ Unknown
<br />$elen Me�er '� -
<br />,; � �
<br />c• 11. FATHER'8•NAME (Firaf, Middle, I Laet, 8uffiz) 12. MOTHER'S-NAME _(Plrat, Mfddle, Mqiden Sumeme)
<br />�k� Olaf B. Rlin enber
<br />� g g ' Sarah Frances McMullin
<br />�"�' ' 13. EVER IN U.3. ARMED FORCE34 �Ive detea ot servlce N yes. 74e.INFORMANT NAME 146, RELATIONSHIP TO DECEDENT
<br />� 1ves,no,o�unk.�Yes 6/1950 7/1954 Helen Kl.ingenberg Wife ,
<br />�� � 18. METH00 pF UISPOSITION 1Ba EMBAI,MER•SIOWATURE 18b. LICENSE N0.' 18c. DATE (Mo.. Day, Yr. ) �
<br />: ❑s�� ❑no�no� Not �Emb�].med Sept. 24, 2010
<br />�" � 18d. CEMEfERY, CREMATOpY 0R OTHER LOCATION CITY / TQWN 8TATE ,
<br />�l Crematlon O Entombment
<br />O Remove� O other (Specly)
<br />�"} Weatlawn. Crematory Grand Island Nebraska
<br />��� 17a; FUNERAL HOME NAMEAND MAILINq ADDRE38 (8lreet, Clry otTOwn, State) 17b. tip Code
<br />�;: Liv�gston-Sondermann Funeral Home 601 N. Webb Road�Grand Island, NE. 68503 �
<br />Zta aaRT I. Enter the chaM ot evema-dlaeasea, �Murles, w eompllaatW�-that directly caused the deaih. DO N0T eMerterminel evente autt� as cardieo anast, � �PR�%IMATE IN7EfiVAI
<br />respiratory arreat, orrentricu�ar iibrllietion without ahawing the edology. DO NOT ABBREVIATE. EMer only one cause on a Me. Ad9 edditionel Iinea fl necessery. i
<br />*IMMEDIAjE CAU3E �onset to death
<br />��ou,�aausEc� � r _t7�c�', �v.\'Ct��t�oc1. QcCe�� �
<br />�� ��9 *DUE T0, OR AS A CON9E0 ENCE OF: ��� � � � � i neet W death �
<br />maemny
<br />i
<br />sequemmnylls�condnronan @) �Or1\►C � �v�\C\Y � �
<br />� �'� DUETO,ORASACON9E�UENCEOF: '
<br />onWrea i m�setrodeaTh
<br />ENet9reUN�EALI7NOCAUSE f
<br />cm�m,� ��� ��Rcgcek� �
<br />ure��mae�n� �
<br />� DUE T0, R A8 A CON3EQUENCE OF. � onaetto death
<br />1�
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<br />PART 11. OTHER SI�NIFICANT CONDIT�O�-G
<br />! �o'�p�:�onei�\ �
<br />5��1� �a(��C�nl �
<br />ro the deefh but �rot Iting tn the undedy g catia ghren In P
<br />aJasc�.ss, ehrori,c �\ Se."@fRtiQ,
<br />, .. � � .. . .
<br />I
<br />i
<br />WAS IdEDICAL EXAMINER
<br />20.IFFEAdALE: � V 21e ^ 21b.IFTRAN8PORTA170NINJd 1o.W &ANAUTOPS RFORMED7
<br />❑ Notpregnen}wfthinpestyear �e�e� �H°midde ��&���� ❑ YES �VO
<br />❑ PragneM at tlme 4f deaih ❑ AacidentO Pending ImesUgaflon � P�enger
<br />❑ Not pregnanl, but pregnaM wtthin 42 days ol dealh � P 81d WEHE AUTOP3Y FlNDINf3S AVAILABLE TO
<br />❑SuiciAe ❑Couldnotbedetermined S
<br />❑ Natpre9rteM,bulpreBneN43dflystalyearbelmedeaN ❑Othar(9peoHy) COMPLEr6CAU3E0FDEATH7
<br />❑ Unknowq (t ptegnant wlNln the pestyear
<br />0 YE3 ❑ NO
<br />22e. DATE OF INJURY (Mo., Dey, Yr.) 22b. TIME OF INJURY 22o.�ptApE OF INJURY-At home, ferm, etreel, fectory, oHice bullding, conetruCllon eke, etc. (Spedty)
<br />�
<br />22tl.INJUBYATWORK? 22e.DESCAIBEHOWINJURYOCCURREO I
<br />❑ YE8 ❑ NO
<br />? CfTYrtOWM S�QE ZIPOODE
<br />�
<br />e. DATE OF D6ATH (Mo., Dgy, Yr.) �� 24a. DATE SIONED (Mo., Day,Yr.) 24b.71ME0FDEATH � �
<br />.�
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<br />� 23b:� E910NHD(Mo.,Day;Yr.) 3o.TIMEOFDEATH ��� 24c.PRONOUNCEODEAD(Ma,Dey,Yr.) 24dTIMEPRONOUNCEOOEAD
<br />Y l �5
<br />$ n �W�� m
<br />3d.To the best of my knowledge, death occurred et the tlme, dete and placs � 24e. On thebesle ot examine�n and/or ImestlgaUon, In my ophdon death xwnedat
<br />�� nd due to the cedae(s) etated.' (SlgneWre end TIUe )♦ � $ �
<br />F o p � the tlme, dafe end plece and due to the cauae(s} steted. (Signature and TNie )♦
<br />�. ��P� . /Y111 9 . ~ Pi e
<br />❑ YES ❑ NO 0 PROBABLY � UNKNOWN
<br />:NAME,TIT^ANDAQDFE390FCERTIFIER(P 81CIAN,COi
<br />u
<br />HA9 OROAN ORTISSUE DONATION BEEN CON9IDERED? 86. WA9 CONSENT ORANTED7
<br />3 YE9 ��, NO Noi AoaliCable If 28e 19 NO ��❑ �YE9 m NC
<br />�,�,� y- 28b. DATE FILED BY RE�IBTRAii q (MO. + �. DaY, Yr.)
<br />/llliQQ�l. �7�1" � ! L�I�
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<br />HH&8111/03(55081) ..
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