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1. DECEDENT'S -NAME (First,
<br />Wilma
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUN 2 7 2007
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUP
<br />CERTIFICATE OF DEATH ; " 58'.5 1
<br />Middle, Last, Suffix) 2. SEX 3. DATE OFDEATH.SMo., Day,Yr.)
<br />E. Rudnick Fe • June 12' 2007
<br />Long Pine, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -26 -9419
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Wedgewood Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9d. STREET AND NUMBER
<br />654 S. Shady Bend Road
<br />10a. MARITAL STATUS AT TIME OF DEATH Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />Edward
<br />18. PART 1. Enter the chain of events -- diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 0 necessary.
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />28a. REGISTRAR'S SIGNATURE
<br />IMMEDIATE CAUSE:
<br />(a) Y" t !' hdA i•-••
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(d)
<br />18. PART t1.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />, (144,6 4,11, wJ a+, . �:. L1wierAti , ry
<br />20. IF FEMALE:
<br />faL Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a ct - O a-
<br />90. COUNTY
<br />22b. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Hall
<br />Hu::ins
<br />CITY/TOWN
<br />2
<br />$ v
<br />y 23b. DATE SIGNED (MO., Day, Yr.) 23c.TIME OF DEATH
<br />▪ -o Ob i - V1-
<br />v 23d. To the best of my knowledge, death occur ed at the time, date and place
<br />c and due to the cause(s) stated. (Signature and Title) •
<br />tYVM rl. h.
<br />201406582
<br />5a. AGE -Last Birthday
<br />(Yrs.) 81
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Last, Suffix) 12. MOTHER'S -NAME (First,
<br />21a. MANNER OF DEATH
<br />Ig Natural ❑ Homicide
<br />❑
<br />Accident0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />5 : m
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient QD XI Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER /Outpatient ❑ Decedent's Home
<br />Theodore Rudnick
<br />OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />2Y
<br />$ t ?
<br />aa
<br />_ a. 4
<br />ad<LI
<br />ai
<br />O U
<br />U 0
<br />Sb. UNDER 1 YEAR
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO
<br />Mae
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />9f. ZIP CODE
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24c. PRONOUNCED DEAD (Mo., Day,Yr.)
<br />TANLEY S. COOPER.
<br />ASSISTANT STATE REGISTRAR ;-
<br />HEALTH ANDS HUPiWI SERVICES -
<br />5c. UNDER 1 DAY
<br />MINS.
<br />6.,DATE OF BIRTH (Mo., Day, Yr.)
<br />August 28, 1925
<br />❑ CO% ❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />68801
<br />Middle,
<br />onset to death
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 24, NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES AI NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES fQ NO
<br />STATE ZIP CODE
<br />24b.TIME OF DEATH
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES XN0 ❑ PROBABLY ❑ UNKNOWN ❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Anne K. Morse M.D. 729 N. Custer Ave., Grand Island, NE. 68803
<br />24d. TIME PRONOUNCED DEAD
<br />26b. WAS CONSENT GRANTED?
<br />JUN 2 5 2007
<br />9g. INSIDE CITY LIMITS
<br />❑ YES RI NO
<br />Maiden Surname)
<br />Coo'
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2- 42
<br />m
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />m
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />
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