201700945 - Laserfiche WebLink

Browse

23a. DATE OF DEATH (Mo., Day, Yr.) February 25, 2008 cn HOURS MINS. 9f. ZIP CODE 9g. INSIDE CITY LIMITS 68801 21 YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. 1. DECEDENT'S -NAME (First, David Wolbach, Nebraska a 7. SOCIAL SECURITY NUMBER ,,•,', 507 -48 -5653 p3 Bb. FACILITY-NAME (If not institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, 68803 'F f% 9a.RESIDENCE -STATE 9b. COUNTY Nebraska Hall sr 9d. STREET AND NUMBER 621 W. 16th 10a. MARITAL STATUS AT TIME OF DEATH Ix Married ❑ Never Married 11. FATHER'S -NAME (First, Edward 15. METHOD OF DISPOSITION XBUdal ❑ Donation ❑Cremation ❑Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final disease or condfion resulting In death) Sequentially list condition, If any, leading to thecause listed confiners. Enter the UNDERLYING CAUSE (disease or injury that initiated the avarnresuhhrg in death) LAST 22a. DATE OF INJURY (Mc., Day, Yr.) STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALT -ANt NIN:SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIO RE; DROV 4FI . WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI> 7 .KOTIOP, 611I IS -. THE LEGAL DEPOSITORY FOR VITAL RECORDS. ° • P a JNL EYS. COO1*R3 S /S7+I4S J8b1GISSTrAl3 ./HIWTH AND HUMAN SERVJDE$ 1 µA � �`�3 C"r 'i FI NAN G4,A(N CI 9TJ P PQ DATE OF ISSUANCE MAR _ 0 4 2008 LINCOLN, NEBRASKA 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at lime 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 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. 23b. DATE SIGNED (Mo., Day Yr.) a lai �o STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. May 15, 1945 (Yes, no, or unk.) Yes Dec 30 , 1946 IMMEDIATE CAUSE: (a) VP DUE TO, OR AS A CONSEQUENCE OF: (b) DUE TO, OR AS A CONSEQUENCE OF: (c) Middle, Last, Suffix) G. Walkowiak 16a. EMB ER- SIGNATURE �Jlt ✓ 1 1 " (t�S.t G) 16d. CEMETERY, CREMATORY OF1 OTHER LOCATION . b DUE TO, OR AS A CONSEQUENCE OF: Middle, Last, L. Walkowiak 225. TIME OF INJURY m Grand Island City Cemetery Grand Island 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines It necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. 23c.TIME OF DEATH 0309 a m 23d.To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) . (Signature and Title) 25. DIDTOBACCO USE CONTRIBUTE TOTHE DEATH? 28a. REGISTRAR'S SIGNATURE 201700945 5a. AGE -Last Birthday (Yrs.) 81 21a. MANNER OF DEATH Natural ❑Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined Suffix) 8a. PLACE OF DEATH HOSPITAL: X Inpatient ❑ ER/Outpatient ❑C04 Mary K. Schaub 14a. INFORMANT -NAME Mary K. Walkowiak 5b. UNDER 1 YEAR 90. CITY OR TOWN Grand Island 9e. APT. NO 12. MOTHER'S -NAME (First, Veronica 165. LICENSE NO. 1092 2. SEX Male 5c. UNDER 1 DAY OI)iER: ❑ Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other(Specify) 8d. COUNTY OF DEATH Hall CITY / TOWN 21b. IFTRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) Middle, C. onset to death Onset to death 21c. WAS AN AUTOPSY PERFORMED? ❑ YES XNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office (wilding, construction site, etc. (Specify) CRY/TOWN 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES �NO ❑ PROBABLY ❑ UNKNOWN ❑ YES x NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTYATTORNEY) (Type or Print) Jennifer Brown M.D. 729 N. Custer AV, Grand Island, NE 68803 28b. WAS CONSENT GRANTED? 3.DATE OF DEATH (Mo., Day, Yr.) February 25, 2008 6. DATE OF BIRTH (Mo., Day, Yr.) November 28, 1926 24b.TIME OF DEATH Maiden Surname) Zauha 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) Feb 28, 2008 STATE NE 17h. Zip Code 68801 APPROXIMATE INTERVAL onset to death 4 dak4 onset to death lLV\ IC-PICA/Ur) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES X NO 22d. INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑ NO STATE ZIPCODE m 24d. TIME PRONOUNCED DEAD m 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title )y Not Applicable i1 26a is NO ❑ YES D( NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 2 9 2008 HHS-61 11/03 (55061)