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STATE OF CAI LZFO1tNZA►
<br />- CERTIFICATION OF VITAL RECORD
<br />Ra TM aan ,
<br />3052012238962
<br />1611 STAGECOACH ROAD
<br />COUNTY OF RIVERSILE
<br />RIVERSIDE, CALIFORNIA
<br />CERTIFICATE OF DEATH 3201233013647
<br />STATE OF CALIFORNIA
<br />USE BLACK INK ONLY / NO ERASURES , WHITEOUTS OR ALTERATIONS LOCAL REGISTRATION NUMBED
<br />VS-11sIR95
<br />STATE FILE NUMBER
<br />1. NAME OF DECEDENT - FIRST (Given) 2. MIDDLE NRY
<br />3. LAST (Family)
<br />GEORGE (HE WANITSCHKE
<br />AKA. ALSO KNOWN AS - Include lug AKA (FIRST, MIDDLE, LAST) 4. DATE OF BIRTH mm /tld /DOW 5. AGE Yrs IF UNDER ONE YEAR IF UNDER,24 HOURS 6 300
<br />02/07/1938 74 60956 ays Hours Minutes M
<br />9. BIRTH STATE/FOREIGN COUNTRY 10. SOCIAL SECURITY NUMBER 11. EVER IN U.S. ARMED FORCES? 12. MARITAL STATUSORDP' (Ol,m,o( 0e,m) 7. DATE OF DEATH rem/del/cow 8. HOUR (24 Hours)
<br />NEBRASKA 507 -46 -3061 ' fl YES X ro ow MARRIED 12/28/2012 0555
<br />13. EDUCATION- Hghest Level/Degree 14/15. WAS 01009005/ HI$PANICAATINO(AWOPAMSH7 (N 580,,8, worksheet an back) 16. DECEDENT'S PAGE Up to 3 races may be listed (sea worksheet on back)
<br />( worksheet 0,m
<br />HS GRADUATE X ❑ No WHITE
<br />17. USUAL OCCUPATION - Type 01 work for most 01(11,. DO NOT USE 0071800 18. KIND OF BUSINESS OR INDUSTRY (8.9.. grocery store. road construction, ,mp(Oymen( agency, etc.) 19. YEARS IN OCCUPATION
<br />BANKER FINANCIAL 47
<br />20. DECEDENT'S RESIDENCE (Street and number. or location)
<br />21. CITY 22. COUNTY/PROVINCE 23. ZIP CODE 24. YEARS IN COUNTY 25. STATE/FOREIGN COUNTRY
<br />DONNNA M. WANITSCHKE, WIFE 611 STAGEC
<br />ANT'S
<br />GRAND ISLAND HALL `68801 57 NE
<br />28.INFO NAME. RELATIONSHIP 1 0' ROAD GRAND ISLA g' 1
<br />28. NAME 57 SURVIVING SPOUSE /SRDP' -FIRST 29. MIDDLE 3 LAST (BIRTH NAME)
<br />DONNA M. LONOWSKI
<br />31. NAME OF FATHER /PARENT -FIRST 32. 64(DDL£ 33. LAST 34. BIRTH STATE
<br />JOSEPH WANITSCHKE? CZECH REP
<br />35. NAME OF MOTHER /PARENT -FIRST 38. MIDDLE 37. LAST (8)8TH NAME) 38. BIRTH STATE
<br />DOROTHY - KARNES VA
<br />39.0t500017(06400764 mmrd72(o46 6 .PL
<br />4ACEOFF(NRLD1SPOS(T)0N ISLAND CEMETERY
<br />01/04/2013 3168 W. STOLLEY PARK ROAD, GRANDJSLAND, NE 68801
<br />41, TYPE OF OISPOSITION(5■ - 42. SIGNATURE OF EMBALMER 43. LICENSE NUMBER
<br />TR/BU ►- MICHAEL WERK P ) EMB9227
<br />44. NAME OF FUNERAL ESTABLISHMENT 46. LICENSE NUMBER 46. SIGNATURE OF LOCAL REGISTRAR 47. OATS mrMad /ocyy
<br />WIEFELS PALM SPRINGS FD836 ► CAMERON KAISER, MD�j 01/03/2013
<br />101. PLACE OF DEATH 102. IF HOSPITAL, SPECIFY ONE 103. 17 OTHER THAN HOSPITAL, SPECIFY ONE
<br />EISENHOWER MEDICAL CENTER X IP ER/OP ❑ 036 ❑ H019600 WON
<br />rc ❑ w a ❑ Other 134. COUNTY 105. FACILITY ADDRESS OR LOCATION WHERE FOUND (S treet anO number, or 1066800) 106. CITY
<br />RIVERSIDE 39000 BOB HOPE DRIVE RANCHO MIRAGE
<br />107. CAUSE OF DEATH 0 /69, 2 chain 01 09,0(1 - diseases. eases. 85005, or complication.-- that 405ptly caused death. 00 907 enter terminal 0080(8 such Tone Everest Between 108 �NHFO181®TOOXTW'
<br />cardiac 9000.6, 0060(015 arrest, orw3Mn0Warli0t720tiai 6,9hout:8Mwv5the Etbb 36
<br />3y. 00 NOT 6480073 0E5066 Death
<br />IMMEDIATE CAUSE OS PNEUMONIA , (69 a Es X NO
<br />of ,m oon �dlaeaa,p ng DAYS
<br />ma mu
<br />in teeth) 109. BIOPSY PERFORMED?
<br />(E3) ) LUNG CANCER ' 1ST)
<br />Sequentially, 6 MOS ❑ YES X 90
<br />conditions. 6 if any, -
<br />leadfng tocause (G) (CT) 110. AUTOPSY PERFORMED?
<br />on UneA Enter
<br />UNDERLYING
<br />CAUSE (disease or YES X NO
<br />irywy that
<br />initiated the events (D) 3 111. USED IN DETERMINING 0720(8101
<br />(68(4005 lo death) LAST ❑ YES ❑ NO
<br />112. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH 807 NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN 107
<br />NONE
<br />113. WAS OPERATION PERFORMED FOR ANY COND(OON IN REM 107 OR 1127 of yes, list type of Operation 638 date) 1134,E FEMME R€dyW MAST AST y£WY7
<br />NO ❑ YES ❑ NO ❑ LINK
<br />114. ICH4OFVIW TUNE 115. SIGNATURE AND TITLEOFCERTIFIER _ 118. LICENSE NUMBER 117.0727E mm/dd /ccm
<br />AT 11-6 FOUR tLNE M4]F.ALF 5683.13 R CY4
<br />CMTFE1�i5TAl�
<br />ca 6M
<br />Decedent Attended Sirre DaLK[Saen42RO 0 DAVID B. KO M.D. e`t A94772 01/02/2013
<br />(A( mm /04 /ccyy (9) mMdd /ccyy (18. TYPE ATTENDING PHYSICIAN'S NAME. MA/LING ADDRESS, ZIP CODE DAVID B. KO M.D.
<br />06/26/2010 12/28/2012 39000 BOB HOPE DR. STE. P -308, RANCHO MIRAGE, CA 92270
<br />119. ILET WIr NFYT INMYCPIWCNCFAIHO ATTT£HJl1R DATE PAD PLACE 000EOFHa'v1TFEC6L6FSSTAT®. 120. INJURED AT WORK? 121, INJURY DATE mmlddhryyl 122. HOUR (74 Hoots)
<br />MANNER OF DEATH ❑ Natural ❑ 400/30,1 ❑ HO rsc/3e O 506008 ❑ 10000/ 5810 detering 700 III NO ❑ UNK
<br />123. PLACE OF INJURY (0.5., home, construction site, wooded area, etc.(
<br />124. DESCRIBE HOW INJURY OCCURRED (Events which resorted in Injury)
<br />125. LOCATION OF INJURY (SIAM a. number, or location. and city, and zip)
<br />128. SIGNATURE OF CORONER / DEPUTY CORONER 127. OATS RMdd /003'9 128, TYPE NAME, TITLE OF CORONER / DEPUTY CORONER
<br />0. STATE A 8 C D FAX IIIIIIInIIIIIIIIIIn11111111nlIIIIf�IIIIInIImnllNnllll�llllllllllllll FAX AUTH.# CENSUS TRACT
<br />REGISTRAR
<br />T10001002237678*
<br />CERTIFIED COPY OF VITAL RECORDS
<br />STATE OF CALIFORNIA 111111111111111111
<br />COUNTY OF RIVERSIDE } SS
<br />This is a true and exact reproduction of the document officially registered and
<br />placed on file in the office of the County of Riverside, C-- * 0 0 1 1 1 4 9 6 2 *
<br />Department of Health. �y y �3'.
<br />J an 10 , 20 { 3 Dr. Cameron Kaiser, M.D., Health Officer
<br />L DATE ISSUED RIVERSIDE COUNTY, CALIFORNIA
<br />This copy not valid unless prepared on engraved border displaying seal and signature of Registrar.
<br />PBNCO (R0) 10/12 �
<br />4 5
<br />REGISTRAR
<br />OF
<br />VITAL
<br />STATISTICS
<br />DDIXESENIGI
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<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE/ ' 1a
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