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<br />42
<br />DOUGLAS COUNTY
<br />avampow
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY NEBRASKA, IT CERTIFIES THE
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/12/2016
<br />OMAHA, NEBRASKA
<br />201604824
<br />ADI POUR
<br />HEALTH DIRECTOR
<br />DOUGLAS COUNTY HEALTH
<br />DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />.o
<br />0
<br />0.
<br />W
<br />311
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dwayne A Ehresman
<br />4.>; AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -38 -2617
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />Nebraska Medicine
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 88198
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />914 8°1.01 Vine Street
<br />15. METHOD OF DISPOSITION
<br />NO WA' ❑Donation
<br />❑Erematiun. ❑Entombment
<br />❑Removal: ❑Other(Specify)
<br />0.
<br />E
<br />0
<br />f3
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Ehresman
<br />E Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />2a.
<br />DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES __
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />28a. REGISTRAR'S SIGNATURE
<br />90. COUNTY
<br />Hall
<br />16a. EMBALMER-SIGNATURE
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />0 Pregnant at time of death
<br />O 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 />DID TOBACCO USE CONTRIBUTE a THE DEATH?
<br />• ❑ YES 404440 ❑ PROBABLY ❑ UNKNOWN
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />83
<br />OS.
<br />5b. UNDER 1 YEAR
<br />DAYS
<br />9e. APT. NO.
<br />16b.LJC O.
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />May 1, 2016
<br />6. DATE OF BIRTH
<br />February 9, 1933
<br />0, pay,
<br />8a. PLACE OF DEATH
<br />HOSPITAL: © Inpatient
<br />© ERlOutpatient
<br />❑ DOA
<br />OTHER: 0 Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68801
<br />f>:l
<br />0
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT-NAME
<br />(Yes, No, or Unk.) Yes 4/15/1953- 4/14/1955 Donna Ehresman
<br />9g. INSIDE CITY LIMITS
<br />Ei Yes No
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Donna Will
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mildred Butcher
<br />14b. RELATIONSHIP!
<br />Spouse
<br />DECEDENT
<br />16c. DATE (Mo., Day, Yr.)
<br />May 7, 2016
<br />160. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cottonwood Cemetery
<br />CrrYITOwN
<br />Burwell
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel;F.uneral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />170. Zip Code
<br />68801
<br />111. PART I, Enter the chain of events - diseases, injuries, or complications that directly. caused the death. "b0NOT eeterrern !ktel 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 Tines if necessary.
<br />IMMEDIATE CAUSE:
<br />1 l+ tr-P.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />h �,�>,!
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a)
<br />in: death) r L ' Re-s
<br />rY cv'� -Qty -y
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If
<br />any, Leading to the cause listed
<br />Enter the UNDERLYING CAUSE
<br />(disease arinjury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF : ;.
<br />c) /
<br />Apt // (r�
<br />DUE TO, OR AS /tCONSEQUEN
<br />OF:
<br />5 ✓a 0s (4 4
<br />onset to death
<br />onstit to:�da di �
<br />Y -4Ctee
<br />ons t to death
<br />t6. PART 11, OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CON7ACTSD?
<br />YES ❑ NO
<br />22b. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />5gkatural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />° K
<br />w / Z. a l <
<br />t ` 21b..13ATE sIGND (Mo., Day, Yr.)
<br />D ' P
<br />C ` / -/
<br />0 ¢ 23d. Toth my knowledge, death occurred at the time, date and place
<br />J3 p and due to the causes) stated. ( ' . . =and Title) fa
<br />23c. TIME OF DEATH
<br />5 -"- Am
<br />22c, MAC OF INJURY
<br />221. LOCATION. OF INJURY - STREETS NUMBER, APT. NO.
<br />CITY/TOWN
<br />ZIP CODE ::
<br />26a. HAS ORGAN OR TISSUE 00NATI
<br />- [.YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />4-2 tr'G ..... 1�, ' s ` t /� c +U 6M c� Z-fafrInktirl Sr- (Oak t tPBlge:
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />BEEN CONSIDERED?
<br />210. WAS AN AUTOPSY PERFORMED?
<br />❑ YES .eNO
<br />21d WERE AUTOPSYFINDINGSAYAILABI.E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />me, farm, street, factory, office building, consttuctjon site, etc. (Specify)
<br />24b. T1ME DEATH
<br />24d. TIME PRONOUNCEDDEAD
<br />m
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />LIIMe
<br />260. WAS CONSENT GRANTED?
<br />Not Applicable U 26a is NO ❑ YES '40
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />MAX .1 2 2016
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