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<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Elton Ruben Walth
<br />- S
<br />2. SEX`
<br />Male
<br />8.4MTE OF DEATH (Mo.. Day,Yr.)
<br />December 11, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />`
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />80
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 17, 1926
<br />Hosrner, South Dakota
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />504 -26 -3661
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Faddy
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<br />B FACILITY-NAME (If not Institution, give street and number)
<br />Good Samaritan Center 1401 East Street
<br />❑ ER /Outpatient Cl Decedenrs Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood River 68883
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />9b.000NTY
<br />Hall
<br />9c, CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1127 S. Cherry St.
<br />9e. APT. NO
<br />9L ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />Ca YES Li NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 3 Married ❑ Never Married
<br />Marned, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.
<br />Violet Graf
<br />11. FATHER'S -NAME (First, ' Middle, Last, Suffix)
<br />Martin Walth
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Josephine Hieb
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service If yes.
<br />(Yes, no, orunk.) No
<br />14a. INFORMANT-NAME
<br />Violet Walth
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. E(ABA �- SIGNATUR . '
<br />` �•''P� ' '
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<br />16b. LICENSE NO.
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<br />16c. DATE (Mo., Day, Yr. )
<br />December 18, 2006
<br />16d. CEMETERY, CREMATORY OR OTHER LOCAT IO CITY / TOWN STATE
<br />Riverside Memorial Cemetery Aberdeen South Dakota
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, CIy orTown, Slate)
<br />Jacobsen - Greenway Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska
<br />1 7b. Zip Code
<br />68873
<br />CAUSE OF DEATH (See instructions and examples)
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<br />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 APPROXIMATE INTERVAL
<br />arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.Add additional lines If necessary.
<br />IMMEDIATE CAUSE: I onset to death
<br />(-:..c- � ! 1I r
<br />IMMEDIATECAUSE (Final (a) "�• r F' y c) G;,
<br />y �` -C;r y� FL-v l 44-4-- I 10 �,t , �,... -.
<br />dlsesaoreandnkmresuRhg DUE TO, OR AS A CONSEQU�ENCE OF: C.) 1 onset to death
<br />In death)
<br />Sequentially Ilstconditions, If (b) - L) c_ a (. w 1,- `" -- O _e 'V -'€t- l ✓ ---1-
<br />leading to du
<br />any, cause listed DUE TO, OR AS A CONSEQUENCE OF:
<br />on fhe a. I onset to death
<br />Enter be UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c)
<br />the h death) '
<br />events resulting
<br />MI DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />�I �^ / `
<br />`, 1 '
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CO TACTED?
<br />❑ YES NO
<br />20. IF FEMALE:
<br />❑ 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 ll pregnant within the past year
<br />21a. MANNER OF DEATH
<br />111 Natural ❑ Homicide
<br />❑Accident❑ Pendng Investigation
<br />❑ Sulfide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Ddver /Operator
<br />❑Passenger
<br />❑ Pedestdan
<br />❑Other (Spedry)
<br />21c. WAS AN AUTOPSY P RE MED?
<br />❑ YES O
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />site, etc. (Spedry)
<br />- 222_rJSE CF.:N.'Dn (Me., Day, Yr.I 22D. 1iwE OF-IINJURY
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<br />22c. PLACE OF INJURY -At home, larm,
<br />street, factory, office building, construction
<br />22d. INJURY AT WORK ?.
<br />Q YES Q NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />121 t I
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<br />24a. DATE SIGNED (Mo., Day,Yr.)
<br />24b.TIME OF DEATH
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<br />23b. DATE SIGNE (Mo., Day, Yr.)
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<br />23c.
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />23d. To the best of my kn ledge, death occurred at the time, date and place
<br />and due to the (s) scaled. (Signature and Title ) V
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<br />u w z O 24e. On the basis of examination and/or lnvestigatlon,
<br />a z o the time, date and lace and due to the
<br />c cc ° p
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<br />In my opinion death occurred at
<br />cause(s) stated. (Signature and Title
<br />() ( fin )
<br />25. DID TOBACCO USE RIBUTETOTHE'1rATH?
<br />❑ YES (JO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 1 N0
<br />26b, WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES
<br />th it. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) �( e or Pnnt) Oined 1:5/and, NE e/gre3
<br />28a. REGISTRAR'S SIGNATURE
<br />A.
<br />2 8b. DATE FILED BY REGISTRAR (Mo., Day,Yr.)
<br />DEC262006
<br />s
<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 CORD QN WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT{ 47cS - SECTIONS WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />DEC 2 8 2006
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA -
<br />2 01605529
<br />may giC
<br />AS$!STANT STATE REC #'Y R
<br />RVT ES
<br />HEAtr H AN6-41 4N,
<br />DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAti_DW ND'SU .
<br />CERTIFICATE OF DEATH' O 3
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