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ti 012 0 97$1STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES r
<br /> rERTIFICATF OF PFATH 348 04
<br /> 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) -_- , - 2.SEX 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Christopher David Lenz Male August 30,2012
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 6a.AGE-Last Birthday 16b.UNDER 1 YEAR 6c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yns.) I MOS. DAYS HOURS i MINS.
<br /> Keamey,Nebraska 32 October 11,1979
<br /> 7.SOCIAL SECURITY NUMBER
<br /> Ba.PLACE OF DEATH
<br /> w 506-19-0211 HOSPITAL;®Inpatient OTHER:❑Nursing Home/LTC ❑Hospice Facility
<br /> 0
<br /> 1-- Bb.FACILITY-NAME(H not Institution,give street and number) ❑ER/Outpatient ❑Decedent's Home
<br /> w Nebraska Medical Center-Clarkson ❑DOA ❑°w•hspBO'h)
<br /> c
<br /> K▪ 8c.CITY OR TOWN OF DEATH(Include Zip Code) 8d,COUNTY OF DEATH
<br /> lu Omaha 68198 I Douglas
<br /> LL9a.RESIDENCE-STATE 9b.COUNTY Sc,CITY OR TOWN
<br /> 6... Nebraska I Hall I Grand Island -
<br /> Iv 9d.STREET AND NUMBER 9e.APT.NO. 1 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> 0
<br /> S= 3116 West 17th Street 68803 -I ®Yea ❑No
<br /> 10a.MARITAL STATUS AT TIME OF DEATH ®Married ❑Never Married 10b.NAME OF SPOUSE(First,Middle, Last, Suffix)If wife,give maiden name.
<br /> li
<br /> a ❑Married,but separated❑Widowed ❑Divorced ❑Unknown
<br /> II Haley Marie McMahon
<br /> E 11.FATHER'S-NAME (First, Middle, Last, Suffix)
<br /> 12.MOTHER'S-NAME(First, Middle, Maiden Surname)
<br /> U David Lee Lenz 1 Linda Mae Nelson
<br /> m 13.EVER IN U.S.ARMED FORCES?Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> I'-' (Yes,No,or Unk.)NO I Haley Marie Lenz I Spouse
<br /> 15.METHOD OF DISPOSITION 116a.E f 'Ap�
<br /> E GN ATURE 16b.LICENSE NO. I 16c.DATE(Mo.,Day,Yr.)()purls, Ontonagon ! 4 y y September 4,2012
<br /> 2❑Cremation ❑Entombment : -�i:
<br /> ORemoesl ❑Olhedapecity) 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> Westlawn Cemetery Grand Island Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Apfel Funeral Home,1123 W.2nd,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 1s.PART I.Eater gm sherd of events-diseases,Injuries.or emendations-that directly caused the death.DO NOT ester terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest,or vestdcalarfibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only em cause on a line.Add additional Anse if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final \\-0.)
<br /> disease,r oondidon resulting a) A iz-0. ,I�Y'1.L.�, ��`Q �_
<br /> In death l r'sV� ♦ Q c 5�:v9.0{Wt1r��
<br /> - DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,If p� �� 5
<br /> any,le leading to the cause listed b) C'.15r_c).,kG t�tll_Rs'S-1; tct i'Il r *OS lgy �1N t.Lt^1.th U
<br /> DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE 5) '1�y� �J ZS,
<br /> (disease or tn)ury that initiated '-Ntp` ( 04 AA .r-g. Anus. .AP r`.l OI.eM«
<br /> the events resulting in death) DUE TO,OR AS A CONSEQUENCE OF: \ onset to death
<br /> LAST
<br /> d) l c-.0P" o ix- -9- t 'f i1.Le.,-N, k..3.Zrt ...3 Vs" Ose--ma CXT t '/RCS
<br /> 18.PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19.WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> IZ
<br /> ❑YES ®'NO
<br /> W 20.IF FEMALE: 21a.MANNER OF DEATH b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> LL 21
<br /> j= ❑Not pregnant within past year ❑Natural
<br /> ❑Homicide 0 Driver/Operator ❑YES 14 NO
<br /> V
<br /> ❑Pregnant at time of death 'Accident ❑Pending Investigation ❑Passenger
<br /> ❑Not pregnant,but pregnant within 42 days of death 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> ❑Suicide 0 not be determined 0 TO COMPLETE CAUSE OF DEATH?
<br /> .O ❑Not pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify) DYES ❑NO
<br /> lm. ['Unknown if pregnant within the past year
<br /> m
<br /> O.
<br /> E 22a.DAV OF INr1URY(Mo.,Day,Yr.) (22b.TIME OF INJURY 22c.PLACE OF INJURY-At home,farm,street,factory,office building,construction site,etc.(Specify)
<br /> �1 a.A 1`t---i_ 1:30 P m
<br /> m Cara. ... Reservoir State Recreation
<br /> O 22d.INJURY AT WORK? 122e.DESCRIBE HOW INJURY OCCURRED
<br /> H DYES 'RNO
<br /> •
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 42254 Hatchery Road Burwell NE 68823
<br /> •
<br /> 23a.DATE OF DEATH` Yr.)Mo.,Day, 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> re - Z
<br /> vLL b\%t Arz_ a'vi- m
<br /> S F- 23b.DATE SIG ED(Mo.,Day,Yr.) ' ' 7.23=-TIME OF DEATH
<br /> m W I o Y O 24c.PRONOUNCED DEAD(Mo.,Day,Yr.) 24d.TIME PRONOUNCED DEAD
<br /> E°c :=i\-i t t2. 1 1:28 -Aa✓1 m 1 E a-i a z m
<br /> F.,'V 23d.To the best of my knowledge,death occurred at the time,date and place u lY
<br /> ,o- PI W y 24e.at the basis of examination ndd due investigation,in my opinion death occurred
<br /> o W and due_to the cause(s)stated.(Si nature and Title) .8 7 at the time,date and place and du•to the cause(s)stated.(Signature and Title)
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> ❑YES TiliN0 ❑PROBABLY ❑UNKNOWN ❑YES 25 NO Not Applicable If 26a Is NO ❑YES ❑NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print)
<br /> Y �s.. , & Emile Omaha, NE 68198
<br /> L,a iz t� - i♦Z, 42nd
<br /> 28a.REGISTRAR'S SIGNATUR , 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> P i,SEP 10 2012
<br /> i
<br /> This certifies this document tube a ttui co � . t H
<br /> py d'f an original record on file with Vital Statistics,Douglas
<br /> County Health Dept., Omaha,Nebraskaa,_.Certified copies must have a raised seal in the area to the left.
<br /> Reproduction of this green'ceriti f cateare not leg t'copies.
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<br /> S�EP�. 10 -2412- 4
<br /> Date Issued: Registrar: . r._� a rift.j.... ..
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