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STATE OF NEBRASKA �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND FI MA�N SERI�ICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE lVEBRASKA�-(3E�'AR�M` �pT�� NEAtTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY EQR V�,�L l�'E�b���;,p. ,, �
<br />.t t
<br />DATE OF ISSUANCE � 012 0 2 2 7 4 ���� ���� .^°�• �`,
<br />07/28/2011 '; ��"�►�'�Y S: Coe�F..� . < , `;>
<br />�S�STAIV�,�T�t]"���{:EGIS�I7AR� '
<br />�EP�R�ME�" �f � L��'H AIV/� r
<br />LINCOLN, NEBRASKA hl�/MX#� SERV��E� ..
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�3 '., fk,r .•' a�' 17 02493
<br />CERTIFICATE OF DEATN - : :,4• -. � t1Fa ���`:`'.�' _ �.' - - -
<br />1. DECEDENTS-NAME (Ffrst, AAlddle, Last, Sufflx) 2. SIX `�. �� a; p 3 bATE OF DE1}7H {Mo, Day, Yr.)
<br />Larry Eugene Wtrth Male• ��> �
<br />4. CITY AND STATE OR TERRffORY, OR FOREIGN COUN7RY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 6c. UNDER 1 DAY` ° B: DA'LE OF BIRTH (Mo., Day, Yr.)
<br />(Y�.} MOS. DAYS HOURS MIN3.
<br />York, Nebraska 61 March 20, 1950
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506-60-8101 HOSPITAL � Inpatlent OTHER ❑ Nursing HomaILTC � Hosplee Facil(ty
<br />8b. FACILITY•NAME (K not InstfpiUon, ghre street and aumber) � ERlOutpafle�rt ❑ DecedenYa Home
<br />�
<br />° Salnt Francis Medical Center ❑ oon ❑ o�ner(specisy)
<br />�
<br />� Bc. CI�1f OR TOWt�t OF DEATh Qrtctude Ztp Code) Bd. COUNTY OF DEATH
<br />'c Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE eb. COUNTY 9c. CITY OR TOVYN
<br />w Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 8e. APT. NO. 8t. ZIP CODE 8g. INSIDE CITY UMITS
<br />�, 106 W. 18th St. 68801 � res ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � MaMed ❑ Never Married 10b. NAME OF SPOU9E (Flrat, Middle, Last, Suftix) If wHe, glve malden mame
<br />� [] Marrled, but seperated [� Wldowed ❑ DWorced ❑ Unknown Peggy Jensen
<br />� 11. FATHER'S•NAME (First, Middle, Last, Suffbc) 12. MOTHER'S-NAME (Flret, Mtddle, Malden Surmama)
<br />m Eugene Wirth Norma Menssen
<br />E 13. EVER IN US. ARMED FORCES? GNe dates oi servlce ff Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) Yes 01/27/1969 Peg Wirth W�fe
<br />,$ 15. METHOD OF DISPOSII'ION 18a. EMBALMERSIGNATURE 78b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burial ❑ Donatlon
<br />Not Embalmed July 25, 2011
<br />� CremaUon 0 EMombmerrt 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speeiry) �ntral Nebraska CremaUon Senrices Gfbbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Tmwn, State) 17b. Zip Code
<br />Apfel Funeral Home,1123 W. 2nd, Grand Island, Nebraska 68801
<br />C SE O DEATH ee nstructions and e�aam les
<br />18. PART 1. Frrtar the chain ot eve�-dlseases, lryurtea, or camppcatlona-that directly caused tlre death. DO NOT eMer terminei evente auch ea oardiac arteat. ; ppPROXIMATE INTERVAL
<br />resplraWry arteat, or ve�rtAwlar Nbrlllatlon without shoMing tlre eHOlogy. DO NOT ABBREVIATE. EMer onry o�re musa on a pna Add addiGonal Wrea IT �ry.
<br />IMMEDIATE CAUSE: ; anset to death
<br />nan�owre cause �� e) Metastasized Colon Cancer 6 About 4 Years
<br />dlaease or conCttion resu�ung
<br />1° �� DUE TO, OR AS A CONSEQUENCE OF: � oneat to death
<br />seyuenae�ry nas conawooa ir b)
<br />a�ry. leatling to tlre cause Ilated
<br />on Ilne a DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />�eer ure urm�rwo cnuse �)
<br />(Aleease orinjurythatlnlGated
<br />tne e°e"m'�utl"8 �" ae�� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />usr �
<br />�
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS�Conditto� eontrlbutlng M the death but not resulUng In the urMariying cause gWan In PART 1. 18. WAS MEDICAL EXAMINER
<br />HepaUc Failure SeCOndary To Hepatic Metestesis oR CORONER CON7ACTED9
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 27e. WAS AN AUTOPSY PERFORMED?
<br />� 0 Na a�e�u � a�s r� � ro� p Ho�maae ❑ m���roae�m. � t�s � No
<br />� � r.�� �s u� m a�u, p a�wa�,e p a�au� �n ❑ a�"e�r
<br />� � Not pregnaM, hut pregnatrt wkhln 42 days ot death swdae coma na ne aeiermi�rea ���" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />� Not P�8�4 but pragnaM 49 daye to 1 year betore deaN � Other (BPeWh)
<br />� ❑ Unknorm ti vre9nant Mthln the P� Year ❑ YES ❑ NO
<br />�' 22a. DATE OF INJURY (Mo, Day, Yr.) ?2b. TIME OF INJURY 22c. PLACE OF INJURY-At homa, tarm, etreet, taetory, oiflee butlding, eo�tructlon sRe, ete. (Specfiy)
<br />E
<br />s
<br />a 22d. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />I�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. , CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />s � July 25, 2011 � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH �� k Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ � O Jul 25, 2011 03:03 AM y a�
<br />� 9d. Ta the best oT my knowledge, death ocaurted et tha tl�, date snd plaee �� �� pqa. On the basis oi exeminatlon and/or Inveatigadon, fn rtry opNlon death ocwrted at
<br />� and due to the muae(s) efated. (Slgnature entl TIUe) � z p the 8me, date entl plaee and due to tire cause(e) sfatetl. (Sig�mture end TIUa)
<br />`' � Steven Husen, MD ~ g a
<br />25. OID TOBACCO USE CONTWBUTE TO THE DEATH9 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOINN ❑ YES � NO Not Appilrable H 28a is NO ❑ YES ❑ NO
<br />27. E, LE D DR F CERTIFIER (P I I T, C RONER P I IAN O O TY A RN (Type or rint)
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Istand, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 27, 2011
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