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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT��ND tlUN1AN �S�RVICES, IT-CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR�ISKA,f9��A�R�MEl1,IT OFF' EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY,FOlt'�C%t�'��4L;R,EC�O�Rl� ,''; �,
<br />ro � i �,� �" o .
<br />DATE OF ISSUANCE -y������� �i. �� � • ,�
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<br />ozi�o�zo�� 2�12�'759"� . �����rs���oPER , ����� ��; ,� �
<br />A�51S�`AN�7�A'�� ;� .
<br />D�'PARFMEl1f7 OF hIE4LtK�INt� -''
<br />LINCOLN, NEBRASKA Ht1MA,,,(�f '���VI�ES �.,� ; ,� x ° �; >
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVI "'�'�� �"S� �'� ' � ��� 11 00378
<br />. .., + � i � f R, e'�rE .er .
<br />CERTIFICATE OF DEATH -� � � e� ';' � � • � w� ?
<br />. DECEDENTS-NAME (Flrst, Middle, Last, Suffbc) 2. SIX ' 3. 6�1TE (Mo., Day,:Yr:)
<br />Henrv Robert Rhoda Male . � Fetin.�arv�3. 2011
<br />OF BIRTH I5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNC
<br />(YB•) MOS. DAYS HOURS
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<br />Cameron
<br />508-247675
<br />Good Samaritan Society-Grand Island �Ilage
<br />. CITY OR TOWN OF DEATH prrclude Zip Code)
<br />Grand Island 688U3
<br />, RE9IDENCESTATE 8b. COUNTY
<br />Nebraska Hall
<br />�' � �
<br />Ba. PLACE OF DEATH
<br />i�RA_,l � Ir�patleM
<br />❑ ER/OutpaUe
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />October 28. 1926
<br />OTHER � Nuraing HomeILTC � Hosplce Facittty
<br />nt ❑ Decedetrt's Home
<br />❑ Other (Specliy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />104 Mecca St.
<br />a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (First, Middte,
<br />❑ Marrlad, but separatad ❑ Wldowed ❑ Dlvorced ❑ Unknown Loretta Marie Van Winkle
<br />. FATHER'3-NAME (Flrst, NOddle, Last, Suffbc) 12. MOTHER'S•NAME (Firs
<br />Henry Rhoda Bertha Henses
<br />. EVER IN US. ARMED FORCES? Give dates of service H Yes. 14a. INFORMANT-NAME
<br />(Yes, No, or unk.) Yes 02/26/1945 Judy Van Winkle
<br />. METHOD OF DISPOSI770N 18a. EMBALMERSIGNATURE
<br />� sunai ❑ oonauon Matthew T. Myers
<br />❑ Crematlon 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />❑ Removal ❑ Other (SP�KY)
<br />Mt. Pleasant Cemetery
<br />a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Smte)
<br />All Falths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />). 8t ZIP CODE 8g. INSIDE CITY UMITS
<br />68824 � vES ❑ No
<br />Last, SuHix) If wNe, glve maiden �me
<br />Middle, Malden Sumame)
<br />18b. UCENSE NO.
<br />1411
<br />CITY / TOWN
<br />Cafro
<br />B. PART I. Fstertfie ahain of eveMe--0I�asea, InJurles, or compllcatlons-that directiy caused Ute death. DO NOT errter terminal everrte such es cardiac arrast,
<br />resplratory artest, or ve�rtdcutar flbdllatlon without ehowing the etlology. DO NOT ABBREVIATE E�rter only one ceuse on e Iine. Adtl add(donat Urtea IT ne�ry.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Flnal a) Cancer Unknown Primary MetastaUc To Liver
<br />disease or condklon resulGng
<br />10 �'� DUE TO, OR AS A
<br />Sequentlaib Iiet conditlons, H b)
<br />at�Y. lesaing m the cause Iieted
<br />on Ilne a DUE TO, OR AS A
<br />E�rter Nm UNDERLYINO CAUSE ��
<br />(dl�ase orinJurythatln(qated
<br />the evente resWting In ueath) DUE TO, OR AS A
<br />wsT d)
<br />OF:
<br />coMribut(np to the death but not resultlng In the underlytng eauae gtven in
<br />14b. RELATIONSHIP TO DECEDENT
<br />Power of Attomey
<br />18c. DATE (Mo., Day, Yr.)
<br />February 7, 2011
<br />STATE
<br />Nebraska
<br />17b. 21p Code
<br />68801
<br />0 APPROXIMATE INTERVAL
<br />; o�et to death
<br />6 One Month
<br />; onsetto death
<br />�
<br />: orreet to death
<br />i
<br />o�et to death
<br />I. WAS MEDICAL DGIMINER
<br />OR CORONER CONTACTED7
<br />❑ YES � NO
<br />I. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 27e. WAS AN AUTOP5Y PERFORMED9
<br />Q Notpregnantwkhln pastyear � NaWral � Homicida � DrIveAOperetor
<br />� Pregnantattlmeoideath �p��M �Pendin8lnvestl8�on ❑�n8er ❑ YES � NO
<br />Q Not preenairt, but pregna�rt wlthln 4z daye ot death su ��� � ����� � Pedestrlan 21d. WERE AUTOPSY FINDINGS AVAILF
<br />� Na vrea�m, nus pre¢naM aa aeye eo � yeer uetore aeam � � ��� �y�qy� TO COMPLETE CAUSE OF DEATH?
<br />� unknrnm li pregront withln the past year ❑ YES ❑ NO
<br />ta. DATE OF INJURY (Mo.. Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office bullding, cons6ucUon alte, etc. (Specffy)
<br />INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES � NO
<br />LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOVYN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />February 3, 2011 ,� �
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME pF DEATH ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Februa 4, 2011 11:25 AM �� a�
<br />0 3d To the bast of my Imowted9e. death occurted at the tlme. tlate end Piaca $�� 24e. On tlre baels ot examinadon anNor ImestleaGon. In my oPWon tleatA occurtad at
<br />� a n d d a e t o U t e c a u s e f s) s t a t e d. ( 3 1 9 n a t u re a n d T t tl e) �� 8 t h e t i n re. d s t e a n d P l s� en d dae t o t h a ea u s e(s) � t e d. ( S � B n ffi u r e an d T i fle)
<br />Donald Wirth, MD g o
<br />, DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTED7
<br />Q YE9 � NO ❑ PROBABLY ❑ UNKNOWN ❑ YE$ � NO Not Appllcable If 28a Is NO ❑ YES ❑ NO
<br />IT D OF C R IFIER (P YSIC , C IST , COR ER S PH SI R C A RNE1n (Type or Prirtt)
<br />Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />a. REGISTRAR'S SIGNATURE /�:J. 28b. DATE FlLED BY REGISTRAR (Mo.. Day. Yr.)
<br />��rl' �'�� February 8, 2011
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