Laserfiche WebLink
D <br />�o a y <br />CD = o � o <br />c -+• <br />m r; z n <br />ry co <br />r� r) .f: �: M z o o Q <br />CID o <br />Q M <br />C�1 � v r n s � <br />vy 00 <br />r, oo to c� <br />c� to <br />U• <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AALL!4UMAN :SERVICES <br />SYSTEM, R CERTHWS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL "WOR"NEIL &WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/C3 SECITQII Vill IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE 1�'�' <br />�l Q EY ' COOP <br />�TAI� <br />LMOLN, NEBRASKA 200004680 HEALTH AND hVMA_N SERVICESS SYSTj* <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEikV ICU FINANCE AND SPORT <br />VITAL STATISTICS -_ � <br />CFRTTFTCATF of DFATH _� — nn E! t nn I R q ,4 <br />rt DECEDENTNAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (Month. Day, Year) <br />Mabel Edna Wentz <br />Female . <br />January 12, 2000 <br />4. CITY AND STATE OF BIRTH Onof in USA. name country) <br />5a. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Year) <br />St. Michael, Nebraska <br />(Yrs166 Sb <br />April 15, 1933 <br />MOS DAYS <br />5c HOURS MIN$ <br />7 SOCIAL SECURTIY NUMBER <br />Ba PLACE OF DEATH <br />508 -38 -0681 <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient - � Residence <br />8b. FACILITY . Name (it not msf tution, give street and number) <br />606 S. Thebe Box 398 68824 <br />❑ DOA ❑ other tSpecdvl <br />8c CITY TOWN OR LOCATION OF DEATH <br />8d INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />Cairo <br />Yes 0 ❑ <br />Hall <br />No <br />9a RESIDENCE STATE COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER Ilnc)uding Zip Code) <br />9e INSIDE CITY LIMITS <br />�Ib <br />Nebraska Hall <br />Cairo <br />606 S. Thebe 68824 <br />® ❑ <br />Yea No <br />10 RACE (e g. White. Black. American Indian <br />11. ANCESTRY (e. g.. IWFan.TMexican. German, etc) <br />12. ❑ MARRIED WIDOWED <br />13 NAME OF SPOUSE /a wife. give maiden name) <br />etc I ISoec,fy) White <br />ISdeartlL.�n /Dutch <br />l]C 11 <br />NEVER DIVORCED <br />ARRI <br />James Wentz ( DEC ) <br />14a USUAL OCCUPATION (Give kindot work done during most 14b <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION IS _city only highest grade completed) <br />of w� even it refired/ <br />Restaurant <br />Elemenl�ryyr Secondary 10 121 College n -4 or 5-I <br />I <br />16 FATHER - NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Ray Post <br />Buela Brundage <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME <br />(Yes no or unk.1 (If yes, give war and dates of services) <br />NO I I Roxanne 7arobson <br />190 ! NFORMANT MAILING ADDRESS !STREET OR R D NO., CITY OR TOWN. STATE, ZIP) <br />1336 Mark Plattsmouth, NE 68048 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION <br />i 21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />Burial Removal 7 <br />1/15 2000 <br />Mt Pleasant Cemetp IZY <br />22e. FNNER HOME -NAME 7i <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- O'Brien- Straatmann F.H. ❑ Cremation ❑ Donatmn <br />Cairo, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />411 West 11th Street Wood River, Nebraska 68883 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND (01 Interval between onset and death <br />PART <br />,a, Cardiac arrest unknown <br />DUE T0, OR AS A CONSEQUENCE OF I Interval between onset and death <br />I <br />(bl <br />DUE TO. OR AS A CONSEQUENCE OF t interval between onset and death <br />I <br />Id I I - <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />111 IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IN THE PAST 3 MONTHS' <br />EXAMINER OR CORONER' <br />(Ages <br />10 -541 Yes No N <br />Yes No <br />Yes No <br />26. <br />26b DATE OF INJURY (Mo.. Day. YrJ <br />ffic HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Acc�tlent � Undetermined <br />M <br />❑ Suc de El Pending <br />26e. INJURY AT WORK <br />261 PLACE QF.INJURY - At home. farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Vey No ❑ <br />o ce b3ding. etc (Specify/ <br />27a DATE OF DEATH (Mo.. Day Yr.) <br />28a DATE SIGNED (Mo. Day. Yr.) <br />28b TIME O DEATH <br />ound apnrox <br />_ <br />t <br />< <br />27b DATE SIGNED (M0. Day Yr) <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD (Mo.. Day, Yrl <br />28d. PRONOUNCED DEAD /Noun <br />M <br />27d To the best of my knowledge- death occurred at the time. date and place and due to the <br />28e. On the basis ply examination and or investigation, in my opinion death occurred a1 <br />8 <br />causelsl stated. <br />° a <br />the time, date and place and due to the causels <br />ISM nature and Title 11, <br />0. Signature and Title) <br />29 DID TOBACCO USE CONTRIBUTE TO THE EARTH? 30.a <br />HAS ORGAN OR TISSUE DONATION CONSIDERED? 30. <br />WAS CONSENT GRANTED' <br />(DE <br />❑ YES ❑ NO I n'I UNKNOWN <br />�BEEE�N <br />❑ YES I �yi NO <br />❑ YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type 0, Pang <br />Dep i Stover HCSO 131 � :,ocustj Grand Island. NF 68801 <br />32a. REGISTRAR <br />32b DATE FILED BY REGISTRAR (Mo.. Day Yr) <br />�" j 6w, I <br />JAN 2 8 2000 <br />Lot Fifteen 15 in Block-Ten in the urigiffial I own ot Cairo, a y, e s a <br />Aso <br />