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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ,Hd�M�l�,11� ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON fILE WITH THE NEBRASK/�D�PA��'N�E�V�O�,HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V�AI, .�S �' ,��
<br />�} ti �� �'.
<br />DATE AF ISSUANCE � • � � 4�� ,� '
<br />09/13/2011 2 012 016 4 7 S T�NfEI` � ,::C'oofi�K` �:, i;� �
<br />, AS,�I�T�9I1JT �TA��G�,TRAft'' ` � � :
<br />DEP,ART ,ME�%O 1�H.pIVD - - ,e'
<br />LINCOLN, NEBRASKA HUMIA SE�t1FICE5 �, , , °` � �`"
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV��E�3r, �' �' ' ��. •' �s y, �
<br />„'• t�,�c�ae c.a-_. ,� .�1 �02981
<br />GERTIFIGATE oF DEATFI y ` '•�:°','�",':� • ��� -�
<br />1. DECEDENT'S-NAME (Firat, Mlddle, Last, SWBx) 2. SEX �� q � �3M�/,TE D TFh(Mo., Day, Yr.)
<br />Ronald Eugene Wolfe Male ��;Augu�ta2; 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. ACiE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY B: DATE OF BIRTH (Mo„ Day, Yr.)
<br />��•I MOS. DAY3 HOURS NUNS.
<br />Cheyenne, Wyomin 84 • April 23, 1927
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />50&20 �❑ inpanera OTHER ❑ N�usi� Home1LTC � Hosplte Faellity
<br />8b. FACILITY•NAME pf not Instihrtlon, glve street and numbe� � ER/OutpaUeM ❑ Deeede�e Ho�
<br />�
<br />� Good Samaritan Society-Crane Meadows ❑ DOA. „� Other(Speclyy4SSISTED UVING
<br />� 84. CffY OR TOWN OF DEATH (Include 21p Code) �� ed. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />7 9d. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMUTS
<br />�` 608 West Charles 68801 � ves ❑ No
<br />� 108. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Marrled 10b. NAME OF SPOUSE (Firat, Middle, l.aet, Su(fl�c) N wife, g(ve maiden name
<br />� ❑ a�mea but separated � v+naowea ❑ oNo►cea ❑ u��owo Margaret Ethel vance
<br />� 11. FATHER'S-NAME (First, Mlddie, Last, Suffiu) 12. MOTHER'S-NAME (Flret, Mlddie, Mlalden Sumame)
<br />Claude Edmund Wolfe Florence Mae Harcleroad
<br />°' 13. EVER IN U.8. ARMED FORCES? Glve dat� of serviee H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �res, No, or unic.) Yes 04/07/1945-07/11/1946 Richard Blane Wolfe Son
<br />� 1S. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Tracey Dietr 1328 August 27, 2011
<br />❑ CremaBon � E�ROmbmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ on,er �specity� Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 W. Znd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructlons and exam es
<br />7B. PART L EMertlre shaln oi eve�-0Ieeasee. InJuriee, or compllmtlons-that dlrecUy caused the deafh. DO NOT eMerterminai eve�Re such as cardiae arrest, : APPROXIMATE INTERVAL
<br />respiraMry arteet, or veMricular flbrlUatlon without shawinp ti�e etlotopy. DO NOT ABBREVIHTE Frrter oniy are cauee on a Me. Add additlo�t Wres H neceasary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />��eou►re cnuse �� a) End Stage Chronic ObstrucUve Pulmonary Disease, Respiratory Failure ;>10 Years
<br />atsease ar contlmon resuttlng t
<br />10 �� DUE TO, OR AS A CONSEQUENCE OF: : cr�set to death
<br />Seque�Ulaliy Itat eondftlone, It b)
<br />am, ieaaio9 m tne ceu� i�ea
<br />on IUre a DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />Errter the UNDERLYIN6 CAUSE C�
<br />(dieeaee or inJury that InMiateA
<br />�ne B`re"m'eann"a m deatiq DUE TO.OR AS A CONSEQUENCE OF: � o�reet to death
<br />� d)
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONSConditlone eontributing to the death but not resulting in the underiytng cause ghren In PART I. 18. WAS MEDICAL EXAMINER
<br />Severe Dementia, ArterioscleroUc Cerdiovascular Disease, Comnary Artery Disease oR CoRONER CONTACTED�
<br />� ❑ YES � NO
<br />� 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AU70PSY PERFORMED?
<br />� � Not prepnant wkhln past year � NaWral � HoMdde � DrlvedOperator �� � NO
<br />v � areanaM ae ame m aeaen p awa�e � Pe�Mln9lmeedpatlon ❑ v��9ef
<br />C] Not pregnant, but prepnant w@hln 42 daye oi death g�qde CoNtl not ue uetermhred ❑ P�� 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />' Q Not Pree�. but Pre9�M � daye w 1 year betore death � � � p�ry� tsp� h1 TO COMPLETE CAUSE OF DEATH?
<br />� � Unimawn ff prepnaM wNhln the past Year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 92b. TIME OF INJURY 22c. PLACE OF INJURY-At home, tartn, atree; factory, office bullding, eorretruetion ette, etc. (Speeity)
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ YE3 ❑ NO
<br />22t. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CffYITOWN STATE ZIP CODE
<br />29a. DATE OF�EEATH (Mo:. Day. Yr.) 24a. DATE SItiNED (Mo., Day, Yr.) 346.'�IME �F DEATH - -
<br />A
<br />� August 22, 2011 S � �
<br />�� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Au ust 23, 2011 02:35 PM �<�
<br />8,� o . ro ttre best ot my knowledee. aeath oeeurred et the d�. tlete aml plaa $ �°
<br />24e. On tire bas� of exeMnatlon endla InvesdgeUon. in my oplNon death oecuned at
<br />�- and due to the cauae►e) efatetl. (8lgnature and Tkle) � p the tlme, datp end ptace end Aue to fhe cauae(s) eteted. (Slgnature and TWe)
<br />~ � Steven Husen, MD ~ � �
<br />25. DID TOBACCO U9E CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEDT
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable H 28a is NO ❑ YES ❑ NO
<br />2. TITLE AND RE E I R YSI ype or Prirrt)
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />288. REGISTRAR'S SIGNATURE � � 2Bb. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />September 12, 2011
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