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STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER*ES CERTIFICATE OF DEATH WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DE Th( ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI74'G RE t '• /< • DATE OF ISSUANCE 10/09/2015 LINCOLN, NEBRASKA 201507373 STANLEY S. COOPEI• . ASSISTANT STATE REGIST P., P DEP4RTIPNr`OF EALTH AND -' HUMAN 4YR4//Ct J .✓ • 15 05661 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Martin Paul Wiedel 2. SEX ^ Mal e° S .3. DATE OP'DEATH (Mo., Day, Yr.) ' September 24, 2015 To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fairbury, Nebraska 5a. AGE - Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 67 MOS. DAYS HOURS MINS. July 9, 1948 7. SOCIAL SECURITY NUMBER 506 -62 -6394 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 ad. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3216 W. 16th St 9e. APT. NO. 9f, ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Jean London 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frank John Wiedel 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Helena Amelia Fischbach 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Mary Jean Wiedel 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Matthew T. Myers 16b. LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) September 28, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Sacred Heart Catholic Cemetery Hebron Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a)Acute Intracranial Hemorrhage 1 Day disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b)Metastatic Squamous Cell Cancer Of Penis 16 Months I any, leading to the cause listed I on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death c) Thromboctopenia 12 Weeks Enter the UNDERLYING CAUSE I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST I d) i I I. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IE NO I. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? LIVES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 24, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 28, 2015 23c. TIME OF DEATH 08:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(a) stated. (Signature nd Title) Chad Vieth, MD 24e. On the basis of examination and /or Investig tion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR 0 YES ISSUE DONATION BEEN CONSIDERED? f 1 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE �" 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 30, 2015 I STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER*ES CERTIFICATE OF DEATH WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DE Th( ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI74'G RE t '• /< • DATE OF ISSUANCE 10/09/2015 LINCOLN, NEBRASKA 201507373 STANLEY S. COOPEI• . ASSISTANT STATE REGIST P., P DEP4RTIPNr`OF EALTH AND -' HUMAN 4YR4//Ct J .✓ • 15 05661