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STATE OF NEBRASKA ` �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR=1%I
<br />DATE OF ISSUANCE
<br />U5/04/2010
<br />2 0120486�
<br />-�
<br />LINCOLN, NEBRASKA
<br />....
<br />Fi�IUD�N�IJvT�JIY ERVICES, lT.�CERi7FIE5
<br />�A A,,�eiART,I,�lEAI�b�F HEALTH /�11�'D
<br />�.;It�EC�Ri�S: � � �
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<br />� r ( � r` • �, ��' I
<br />Y . COOPER � � � �
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<br />911f�� S�Fi4T� R�GISTR.46t ;
<br />�t'�vr��t�reaa Anip s , � %
<br />S�RVIGES �:: ,k,• ,,.� '
<br />• �. �-
<br />3TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV/ICE�, ��,:'� � r `� ��� n"-'
<br />'� --. 1(1 07 0_�d
<br />� � � �. �7 . . , ���_
<br />-- - --- -
<br />1. DECEDENTS-NAME (Fhst, Mlddle, Laet, Sufflu) 2. SDC '' .� � 3, DATE OF,DF�4TH (Mo., Day, Yr.)
<br />Ramona Lucille Werner Female' °`�-'�4pr11°12, 2010
<br />4. �ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDBR 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•1 MOS. DAYS HOURS MINS.
<br />Cairo, Nebraska 91 September 8, 1918
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH '
<br />505 OSH PITAL ❑ InpaUerrt OTHER � Nursing HomelLTC � Hosplee Facllity
<br />8b: FACILITY-NAME (If rrot Institution, glve street and number) ERIO
<br />� ❑ utpatlent ❑ DecedenYs Home
<br />� Wedgewood Care Center ❑ ooA p omer (speciry>
<br />� 8e. CITY OR TOWN OF DEATH prrclude 21p Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d: STREET ANp NUMBER 9e. APT. N0, 8L ZIP CODE 8g. INSIDE CITY LIMff3
<br />�, 4034 Scheel D�ive 68801 � res ❑ No
<br />� 108: MARITAL STATUS AT TIME OF DEATH � Mar►led ❑ Never Nlartled 70b. NAME OF SPOUSE (Flret, Middle, Last, surnzf rcw�te, glve malden rmme
<br />� ❑ nne�ad but aeparated ❑ v�naoWea ❑ on�or�a ❑ u��, LeRoy Wemer
<br />� 11. FATHER'S-NAME (Flrst, Middte, Last, Sufflx) 12. MOTHER'S•NAME (First, Nllddle, Malden Sumame)
<br />m Arthur Tagge Anna SUenke
<br />�' 73.'EVER IN U.S. ARMED FORCES? Give dates of aeMee ii Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� {res, No, or unic.� No LeRoy Wemer Husband
<br />� 1S. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ Donatlon
<br />Tracey Dietz 1328 April 21, 2010
<br />❑ Crematlon Q Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� Removai ❑ Other (Specffy) Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND NUULING ADDRESS (Streek City or Town, State) I 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska � 68801
<br />CAUSE OF D TH See instructions and exam tes
<br />18. P/1RT I. Enter the chaln oi evenm�-0Iseesea, InJuHea, or compllcaUon�that dlrectiy cauaed the death. DO NOT e�ner tertninel eveMS auch ae cardlac rtaet, � qPPROXIMATE INTERVAL
<br />�reapiratory artest, or ventricuiar flbrlllaUon without ehowing ttre etlology. DO NOT ABBREVIATE EMer only o�re muse on a Ihre. Add additlonal llrtae f( neces�ry.
<br />IMMEDIATE CAUSE: � onset to death
<br />IMMEDIATfi CAU9E (Flnal a) Pulmonary Hypertension ; Years
<br />dlaease or contltUOn resulUng --� . . � --
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />B�ueMlally Ilet eonditlona, H b)
<br />erry� Ieading W the cauee Ilsted =
<br />on IIRe a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />E�rterthe UNDERLYIN� CAUSE �y
<br />(dlsBasa or InJury that inidated
<br />� vente resultine �n death) DUE TO, OR AS A CON3EQUENCE OF: 7 onset to death
<br />dJ
<br />1e. PART II.OTHER SIGNIFICANT CONDITIONS-CorMitlona contributing M the death but not resulUng In the underiying cause given In PART 1. 79. WAS MEDICAL EXAMINER
<br />Myelodysplastic Syndrome OR CORONER CONTACTED?
<br />� ❑ YES Q NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. W/�S AN AUTOPSY PERFORMED7
<br />li.
<br />� �� NOt pregna�Rwlthi� pasf y0a1 � NetU�81 � HOIIIICItle � DIIVef/OpBt8t0�
<br />v O''� Pregna�rt at tlme ot death � Acddent � PenGIn8lmesd9aUOn ❑ Peasen8�' ❑ YE$ � NO
<br />� Not pregnairt, but pregnantwnhin 42 daya ot death � pedestri¢n 21d. VYERE AUTOPSY FINDWGS AVAILABLE
<br />'� � Not pragnant, but pregna�rc 43 tlaye to 1 year berore death ❑$uiWde � Could not be aeteimi�rea ❑�r,s��) TO COMPLETE CAUSE OF DEATH7
<br />� Q�' Unknown H P�eB�M wlthin tha Peet Year ❑ YES ❑ NO
<br />Gt
<br />E 22a. DATE OF INJURY (Mo., Oay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, atreet, factory, office bulldi�, consWction site, ete. (Specify)
<br />�
<br />� ZZd. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />'' , ❑ v�s ❑ No
<br />22f. LQCATION OF INJURY . STREET & NUMBER, APT.NO. CffY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day,_Yr.) __ _ 24b. TIME OF DEALi _
<br />� �i April 12, 2010 � � �
<br />� �' 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED QEAD
<br />� ���y
<br />E�.,Z A ril 13, 2010 11:45 PM � a�� `i�;
<br />$�' � . To the best oi my knowtetlge. death occurtetl at the tlme. da[e a�M lace �
<br />P 24e. On Ne baeis M examinadon and/or InveatlBaUon. In my opinlon death .�F,
<br />��', ana a�re eo sne m�e� emma. �s�enaeure ana rma� � f& o Ure tlme, tlate and place and dua to the eau�(e) etated. (SlgnaWre and T(tle)
<br />~ Travis S. Hageman, MD '' � ;
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH9 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED4 =
<br />YES [] NO ❑ PROBABLY � UNPWOWN � YE9 � NO NotApplicable H26a IS NO ❑ YES ��VO
<br />2. TI LE D 0 ER 1 I R(P Y IC , ASS , O R PHY I R OUN A E1� (Type or PAM �
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo„ Day, Yr.)
<br />April 15, 2010
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