|
WHEN THIS COPY CARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH {III SERVICES
<br />SYSTEM R CERTiFES THE BELOW TO BE A TRUE COPY OF THE OR1fGIN&-*M1V FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STJtTlSTic H IS
<br />THELEGAL DEPOSITORYFOR VITAL RECORDS,
<br />DATE OF ISSUANCE
<br />ER
<br />00 7010 x:
<br />APR 12 2000 - $IgiR�R
<br />LINCOLN, NEBRASKA HEALTH AND Fib/ S1ftTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AN6 HUMAN.SA FiNANQEIND SUPPORT
<br />ZOO 10 2 89 V1TAL STATISTICS - t.
<br />CERTIFICATE OF DEA -fR- -
<br />. I DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IM-11' 0,Iv Yea"
<br />-Elmer William Petzoldt
<br />Male
<br />April 7, 2000
<br />4 CITY AND STATE OF BIRTH dif not in LISA.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />(�
<br />(Yrs1
<br />M
<br />rn
<br />_
<br />ScHOURS Mws
<br />,
<br />81
<br />O
<br />r
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -46 -2429
<br />HOSPITAL ❑ Inpatient OTHER ® Nurs,muH.—
<br />- -- OT
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name (If not institution. give street and number)
<br />i�
<br />❑ DOA ❑ Other (SP-4
<br />C�
<br />8d INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island
<br />in
<br />vi
<br />C
<br />0
<br />9d. STREET AND NUMBER (Includlno Zip Code) 9e INSIDE CITY L T
<br />Nebraska
<br />C D
<br />Grand Island
<br />2309 W. 4th St. 68803 Ye,U NcL_j
<br />U)
<br />�
<br />t2. r–] MARRIED ❑ WIDOWED
<br />t 3 NAME OF SPOUSE iIf rl? c::e ma. CCn ray ^e;
<br />etc I fsri —lyl
<br />White
<br />rn
<br />IX
<br />DIVORCED
<br />❑
<br />O
<br />C2.
<br />MARRIED
<br />14a USUAL OCCUPATION (Gyve kind o/ work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completedl
<br />p �
<br />Y0
<br />C n
<br />a --n
<br />-*1
<br />p
<br />Ern
<br />WAS DECEASED EVER w US. AR I19a. INFORMANT -NAME
<br />es ^o or unk.) III yes glue war and dates of se -cesl
<br />Yes WWII 6- 19-- 1945/8 -26 -1946 Lavern Petzoldt
<br />19b ! NFORMANT MAILING ADDRESS (STREET OR R.F.D NO., CITY OR TOWN. STATE. ZIP)
<br />215 Sunny Dr., Doniphan, Nebraska 68832 ,__
<br />'*T
<br />=NAT
<br />Park
<br />y Apr. 11 2000 Westl_a_wn Memor ia_l___'_
<br />'/ [XI rirlal ❑Rem° al p
<br />Z
<br />1,_a
<br />VJ
<br />p
<br />200102094
<br />23 IMMEDIATE CAUSE EN7 ONLY ONE CAUSE PER LINE FOR fat. Ib;. AND (cll Interval between ousel and d'ealn
<br />PART �'I � '(
<br />_ J(
<br />DUE TO. 08 AS A CONSEQUENCE OF Inter al between ousel and °earn
<br />m t' .
<br />-a
<br />n
<br />26a 26b. DATE OF INJURY IMO. Day. Yr) 26c HOUR OF INJURY 26d. DFSCRIBE HOW INJURY OCCURRED
<br />❑ Accident Undetermined M
<br />r Soode Pendmq
<br />26e. INJURY AT WORK
<br />261 PLACE OF INJURY -t home, farm street. factory
<br />269 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Invest'ganon
<br />Yes ❑ No El
<br />�
<br />r zr
<br />Cv
<br />r«
<br />270 DATE OF DEATH I11o.. Day YU1
<br />28a DATE SIGNED (Mc. Day Yrl
<br />28b TIME OF DEATH
<br />April 7,2000
<br />n
<br />F-
<br />__ M
<br />°
<br />27b DATE SIGNED Ml Day Yrl
<br />W
<br />Cz
<br />28d PRONOUNCED DEAD (Hour
<br />co
<br />o1
<br />II
<br />10 2000
<br />7:38am M
<br />n
<br />C.0
<br />co
<br />27d io the best of m kno d Ih Occur' al Ih U e. tlale antl Dlace and due to the
<br />28e. On the basis of exammallon and-Or investigation, In my op.mon death occurred al
<br />° a
<br />Lauselsl stated,(°
<br />w
<br />the time, date and place antl due to the cause(sl statedISI
<br />nature an Itlel V
<br />IS nature and Title) ►
<br />29 TOBACCO USECONTRIB TE TO THE DEATH?
<br />9,
<br />WAS CONSENT GRANTED-
<br />E
<br />C0
<br />❑ YES NO
<br />�
<br />31 NAME AND ADDRESS OF CERTIFIER IPH SICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( 'Type or Pr. tJ
<br />r Dr John A Wagoner,MD. Alpha r t Grand Island,NE 68803
<br />320. REGISTRAR
<br />32b DATE FILED BY REGISTRAR (Mo. Day Yr)
<br />/Z" )�
<br />APR 112000
<br />-
<br />o
<br />WHEN THIS COPY CARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH {III SERVICES
<br />SYSTEM R CERTiFES THE BELOW TO BE A TRUE COPY OF THE OR1fGIN&-*M1V FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STJtTlSTic H IS
<br />THELEGAL DEPOSITORYFOR VITAL RECORDS,
<br />DATE OF ISSUANCE
<br />ER
<br />00 7010 x:
<br />APR 12 2000 - $IgiR�R
<br />LINCOLN, NEBRASKA HEALTH AND Fib/ S1ftTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AN6 HUMAN.SA FiNANQEIND SUPPORT
<br />ZOO 10 2 89 V1TAL STATISTICS - t.
<br />CERTIFICATE OF DEA -fR- -
<br />. I DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IM-11' 0,Iv Yea"
<br />-Elmer William Petzoldt
<br />Male
<br />April 7, 2000
<br />4 CITY AND STATE OF BIRTH dif not in LISA.. name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH IMm#7 Day Year/
<br />(Yrs1
<br />Sb MOS DAYS
<br />ScHOURS Mws
<br />St. Libory, Nebraska
<br />81
<br />O
<br />July 30, 1918
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -46 -2429
<br />HOSPITAL ❑ Inpatient OTHER ® Nurs,muH.—
<br />- -- OT
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name (If not institution. give street and number)
<br />Tiffany Square Care Center
<br />❑ DOA ❑ Other (SP-4
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Grand Island
<br />Yas NoM I Hail m
<br />9a RESIDENCE - STATE
<br />191, COUNTY
<br />91 CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Includlno Zip Code) 9e INSIDE CITY L T
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2309 W. 4th St. 68803 Ye,U NcL_j
<br />10 RACE - le.g.. White. Black American Indian.
<br />I1. ANCESTRY le q Italian. Mexican. German. etc)
<br />t2. r–] MARRIED ❑ WIDOWED
<br />t 3 NAME OF SPOUSE iIf rl? c::e ma. CCn ray ^e;
<br />etc I fsri —lyl
<br />White
<br />(Specify)
<br />American
<br />IX
<br />DIVORCED
<br />❑
<br />Ruby Marie Spiehs
<br />MARRIED
<br />14a USUAL OCCUPATION (Gyve kind o/ work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completedl
<br />_
<br />EI en
<br />tiiyd ad�re0 121 College n 40 --
<br />of worh,ng Irle. even 't reluedl
<br />Farming
<br />Agriculture
<br />IFATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Ern
<br />WAS DECEASED EVER w US. AR I19a. INFORMANT -NAME
<br />es ^o or unk.) III yes glue war and dates of se -cesl
<br />Yes WWII 6- 19-- 1945/8 -26 -1946 Lavern Petzoldt
<br />19b ! NFORMANT MAILING ADDRESS (STREET OR R.F.D NO., CITY OR TOWN. STATE. ZIP)
<br />215 Sunny Dr., Doniphan, Nebraska 68832 ,__
<br />& LI NO �� , i 21 a. METHOD OF DISPOSITION 21b. DATE T. CEMETERY OR CREMATORY NAME 1 `� ff-
<br />=NAT
<br />Park
<br />y Apr. 11 2000 Westl_a_wn Memor ia_l___'_
<br />'/ [XI rirlal ❑Rem° al p
<br />_ -
<br />220 FUNERAL NOME✓ AME — �� - CEMETERY OR CREMATORY LOCATION C17V JG TOWN STATE
<br />�21cf
<br />Livingston- Sondermann F.H. Cremation ❑°°naup Grand Island, Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23 IMMEDIATE CAUSE EN7 ONLY ONE CAUSE PER LINE FOR fat. Ib;. AND (cll Interval between ousel and d'ealn
<br />PART �'I � '(
<br />_ J(
<br />DUE TO. 08 AS A CONSEQUENCE OF Inter al between ousel and °earn
<br />(bl
<br />DUE TO OR AS A CONSEQUENCE OR.:
<br />r(ER SIGNIFICANT CONDITIO onddtuns contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PAR PREGNANCY IN THE PAST 3 MONTHS' - EXAMINER OR CORONER?
<br />(Ages 10 -54) Yes D No Yes No Yes _ No
<br />26a 26b. DATE OF INJURY IMO. Day. Yr) 26c HOUR OF INJURY 26d. DFSCRIBE HOW INJURY OCCURRED
<br />❑ Accident Undetermined M
<br />r Soode Pendmq
<br />26e. INJURY AT WORK
<br />261 PLACE OF INJURY -t home, farm street. factory
<br />269 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Invest'ganon
<br />Yes ❑ No El
<br />office budding, etc lSpeci/y/
<br />270 DATE OF DEATH I11o.. Day YU1
<br />28a DATE SIGNED (Mc. Day Yrl
<br />28b TIME OF DEATH
<br />April 7,2000
<br />n
<br />__ M
<br />°
<br />27b DATE SIGNED Ml Day Yrl
<br />C c7c7 TIME OF DEATH
<br />29c PRONOUNCED DEAD IMO_ Day, Yr.I
<br />28d PRONOUNCED DEAD (Hour
<br />o1
<br />II
<br />10 2000
<br />7:38am M
<br />___ M
<br />27d io the best of m kno d Ih Occur' al Ih U e. tlale antl Dlace and due to the
<br />28e. On the basis of exammallon and-Or investigation, In my op.mon death occurred al
<br />° a
<br />Lauselsl stated,(°
<br />the time, date and place antl due to the cause(sl statedISI
<br />nature an Itlel V
<br />IS nature and Title) ►
<br />29 TOBACCO USECONTRIB TE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED-
<br />, ❑ VEST` NO UNKNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />�
<br />31 NAME AND ADDRESS OF CERTIFIER IPH SICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( 'Type or Pr. tJ
<br />r Dr John A Wagoner,MD. Alpha r t Grand Island,NE 68803
<br />320. REGISTRAR
<br />32b DATE FILED BY REGISTRAR (Mo. Day Yr)
<br />/Z" )�
<br />APR 112000
<br />u
<br />DESCRIPTION: All of Lot Eighty Eight (88) and the North Twenty ( "�20')
<br />of T.nt F.ityhty Seven (87) - in Belmont Add 1t ion to Lhe Citv of (' rand l:;iand
<br />b Q
<br />
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