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17N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AMQ Efi� L! �I 4 a <br />EM, IT CERTIFIES THE BELOW_TO BE A TRUE COPY OF THE ORIGINAL j i' <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />COOM <br />APR 10 2001 200105 410 = �R <br />ass; GAR <br />LINCOLN, NEBRASKA HEALTH NI}F ' - _ BY�f <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND S�PnnPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATIf 0_1 03575 <br />t. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX '-'_= <br />.DATE OF DEATH tMonm Day. Yearl <br />Donald Eugene Wernke <br />Male <br />March 27, 2001 <br />4, CITY AND STATE OF BIRTH 111 nol i1 U S.A.. name country) <br />5a. AGE - Last Birthday <br />UNDER i YEAR <br />UNDER 1 DAY <br />16. DATE OF BIRTH /Month. Day Year/ <br />5b MOS. DAYS <br />5c. HOURS MINE. <br />Atkinson, Nebraska <br />(Yrs l <br />78 <br />June 23i 1922 <br />Z SOCIAL SECURTIY NUMBER <br />Ba PLACE OF DEATH <br />HOSPITAL. ® Inpatient OTHER. ❑ Nursing Home <br />507 <br />-12 -0027 <br />❑ ER Outpatient ❑ Residence <br />FACILITY Name /N not ms6tufcin, give street and number) <br />8b. - <br />St. Francis Medical Center <br />❑ DOA ❑ Other /Spec,ty <br />Bc. CITY. TOWN OR LOCATION OF DEATH &1 INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island - _.. - <br />�No <br />Homicide <br />Yes <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY TOWN OR LOCATION <br />9d. STREET AND NUMBER hncluding Zip Coder <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />210 E. Charles 68801 <br />Yes ❑X No ❑ <br />10. RACE - (e.g.. White. Black. American Indian. <br />11. ANCESTRY le g Italian. Mercian. German, etc) <br />7`0 MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE lit wife. give maiden name) <br />etc.) (Specify) White <br />(Soecdyl American <br />I <br />NEVER DIVORCED <br />MARRIED <br />Donna Schuck <br />14a. USUAL OCCUPATION /Give kind of work done during most <br />t 4b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed( <br />of working life, even d reored) <br />Elementary or Secondary (0.121 College 11 -4 or 5 <br />Bureau of Relclaimation <br />U.S. Government 10 <br />16. FATHER -NAME FIRST MIDDLE LAST <br />77 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Hildred Wernke <br />Matilda May `Liska <br />18. WAS DECEASED EVER W U.S. ARMED FORCES? <br />19a INFORMANT -NAME <br />YYes•nk) elgive 10 /16/1943 12/24/194P <br />Donna Wernke <br />19b INFORMANT MAILING ADDRESS (STREET OR R D NO., CITY OR TOWN STATE. ZIP) <br />Charles, Grand Island, NE. 68801 <br />20/URE 8 LICEN SE NO. G c / <br />�LMER <br />21a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />//7 <br />✓WC Cta, • �, ,� -l-�f l �/� 1/ <br />© Burial ❑ Removal <br />arch 31, 2001 <br />Grand Island Cemetery <br />,) <br />22a FUNERALY40ME NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes <br />❑ Cremation ❑ Donafol <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) <br />1123 West Second, Grand Island, NE 68801 <br />23. IMMEDIATE CAUSE (ENTER NLY ONE CAUSE PER LINE FOR lat. (b). AND (c)) Interval between onset and death <br />PART <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CO ER5 PHYSICIAN OR COUNTY ATTORNEY( hype or Print) <br />Sitki opur .D. 2 16 West Faidley Ave., Grand Island, Nebraska 68803 <br />DUE TO, OR AS A CONSE ENCE OF Interval between ousel and death <br />C I tiYW_1 <br />ro) <br />DUE TO OR AS A U0NSEUUtNUt tF <br />(c OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me death but not relatee PART <br />III IF FEMALE. WAS THERE A <br />2�IeN.� <br />WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />ppg7 PREGNANCY <br />-' <br />IN THE PAST 3 MONTHS <br />(Ages 10 -54) Yes No <br />Yes No <br />26a <br />26b. DATE OF INJURY IMo. Day. Yr.) <br />HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />nAccident F-1 Undetermined <br />126c <br />M <br />Suicide ❑ Pending <br />26e. INJURY AT WORK <br />261 LLAq g <br />buOilAi INJURY tS� yl farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Investigation <br />❑ ❑ <br />o6ice <br />Homicide <br />Yes No <br />27a. DATE OF DEATH IMo Day YO <br />28a. DATE SIGNED /Mo.. Day Y0 <br />28b TIME OF DEATH <br />a a� �► <br />��� <br />M <br />27b. DATE SIGNED (A o_ Day. Y.4 <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD tMo Day, Yrl <br />2Btl. PRONOUNCED DEAD /Hour <br />$ u9 <br />$ c,, <br />Y <br />¢ zF5 <br />L fq <br />M <br />27d. To the best of my know) ge. ath oc urr at the late ano place and due to trill <br />Be 2 On Me basis of examination and or investigation, in my opinion Beam occurred at <br />Y <br />_ <br />< <br />causels) stated, <br />' <br />a <br />the time. date and place and due to the cause(sl stated. <br />(Signature and Tidel <br />IS nature and Title <br />29. DID TOBACCO USE CONTRIBUTUP 7E EATH? <br />30.e HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED' <br />❑ ❑ NO NKNO <br />❑ YES �/NO <br />YES ®ENO <br />YES <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CO ER5 PHYSICIAN OR COUNTY ATTORNEY( hype or Print) <br />Sitki opur .D. 2 16 West Faidley Ave., Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY fCTRAR / y. Yr.) <br />AA RR 200 <br />