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9 .l biro = s.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -5Q -7420
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health, St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE COUNTY
<br />Nebraska 19b.
<br />Hall
<br />9d. STREET AND NUMBER
<br />1624 N. St. Paul Road
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME
<br />(Yes, No or Urfk.) No
<br />15. METHOD OF DISPOSITION 16a. EMBALMER - SIGNATURE
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑Removal ;❑ Other: (Specify)
<br />Sequsttially list Cpitditions, K t
<br />any, leading to the cause listed - --
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease er lnjury:that MR/0
<br />the events resuaing in death)
<br />LAST
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE DF MEATH (Mo., Day, Yr.)
<br />January 24.2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Janua 25 2017
<br />Laurie D. Sheffield
<br />Westlawn Cemetery
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Persistant lleus
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8a. PLACE OF DEATH
<br />HOSPITAL Q( Inpatient
<br />❑ EWOutpatient
<br />❑ DOA
<br />Ronald Robert Witherwax
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />1 9c. CITY OR TOWN
<br />' Grand Island
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle,
<br />E) Married but separated'; ❑ Widowed ❑ Divorced ❑ Unknown
<br />Ronald Robert Witherwax
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Ephraim Trautman Ethel DeJung
<br />Middle,
<br />1 180. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />CAUSE OF DEATH (See instructions and examples)
<br />18 PART!. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory aneltt, Ca ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Flash Pulmonary Edema
<br />disease or condition resulting
<br />in death)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />a Other(Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />N O
<br />Y W 2
<br />gZ�
<br />a°-
<br />❑ Hospice Facility
<br />1 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />68801 II YES ❑ NO
<br />Last, Suffix) If wife, give maiden name
<br />STATE
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />January 30, 2017
<br />24b. TIME OF D
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Hours
<br />onset to death
<br />20. IF FEMALE:
<br />® Not pregnant within peat year
<br />❑ Pregnant at time of death
<br />❑ Nat 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 />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)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ' E NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />El YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />23c. TIME OF DEATH
<br />02:16 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Richard Fruehling, MD
<br />25. TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES El NO ❑ PROBABLY ❑ UNKNOWN
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES El NO Not Applicable if 26a Is NO ❑ YES
<br />24c1. TIME PRONOUNCED DEAD
<br />Sutton Nebraska;'
<br />MOS. DAYS
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2/2/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Betty Marlene Witherwax
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />201700923
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />Female January 24, 2017
<br />5a. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr,)
<br />(Yrs.)
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />HOURS MINS.
<br />ate
<br />August 30 1941
<br />17 01226
<br />28b. DATE FILED BY REGISTRAR (Mo Day, Yr.)
<br />January 31, 2017
<br />
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