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%'P RAW a\. u U MONAVt. ` NN' , Add ataa an. Ii , Ut A / AO STATE OF NEBRASKA atg WHEN THIS "'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE Or ISSUANCE 12/15/2016 LINCOLN, NEBRASKA 20170207 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 11. FATHER'S -NAME (First, Middle, Last, Suffix) w John Wolf 4 t r 0 1- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Amy Elizabeth Wolf 4. CITY' AND STATE OR TER RITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -82 -2609 8b. FACILITY- NAME Of not tristitution, give street and number) 2504 West Oklahoma Avenue 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 6.8801 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 2504 West Oklahoma Avenue 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ® Never Married ❑ Married, but separated! ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No . . 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ ; Removal .❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) id. PART I. Soler the Chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratoty arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) .. .., Sequkknially ((at conditions If " any, leading to the reuse bated' on line'a. Enter the UNDERLYING CAUSE :(disease or injury::That in(tiated: the events resulting; in death) LAST 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.:INJURY AT WORK ?.. ;: yes . NCI 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon DUE TO, OR AS A CONSEQUENCE OF: b) Heart Attack DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF ® Not pregnant within past year ❑ Pregnant at time of death Not pregnant „but pregnant within 42 days of death Q Not pregnant, tut pregnant93 days to 1 year before death Q Unknown if pregnentwithin past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 44 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY /TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH J a 0 3d. To the best of my knowledge, death occurred at the time, date and place B V and due to the cause(s) stated. (Signature and Title) a w f 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ EROOutpatient ❑ DOA 9c. CITY OR TOWN Grand Island DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 3. 14a. INFORMANT-NAME John Wolf 16b. LICENSE NO. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Decedent Was On Bipolar Medications 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) December 5, 2016 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) December 4, 2016 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Garrett Schroeder, Hall Deputy County Attorney, 231 S. Locust, P • Box 367, Grand Island, Nebraska, 68802 28a REGISTRA IGNATURE je j STATE 21d. WE TO 6. 22c. PLACE OF INJURY -At home, farm, street, factory, office building, cons 24b. 24d. 24e. On the basis of examination and /or investigation, i the time, date and place and due to the cause(s) Garrett Schroeder, Hall Deputy Coun 26b. WAS CON Not Applicable if 28b. DATE FILED December OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) April 8, 1972 9f. ZIP CODE 68801 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 112. MOTHER'S -NAME (First, Middle, Maiden Surname) Linda Weingarten «PY?votAt4.. ('FA A ' ariYY 1610435 DATE OF DEATH (Mo., Day, Yr.) December 2, 2016 DATE OF BIRTH (Mo,,!Day, Yr.);., ❑ Hospice Facility 9g. INSIDE CITYLIMITS YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Father 1 6c. DATE (Mo., Day, Yr. December 5, 2016 STATE Nebraska 17b, Zip 68801 APF'ROXtMATE:INTEI onset to death Minutes onset to death: Minutes onset to death onset to deal AL 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? J YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO RE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? YES ❑ NO ruction site, etc. (Specify) TIME OF DEATH Approx. 12.00 PM TIME PRONOUNCED D 01 :06 PM n my opinion death occurred at stated. (Signature and Title) ty Attorney SENT GRANTED? 26a is NO ❑ YES BY REGISTRAR (M O.; Day, Yr. 12,201E,