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<br />WHEN THIS COPY CARRIES TIE: RAISED SEAL OF THE NEBRASKA HEALTH A- AD_44 -44 SERVICES
<br />SYSTEM, R CERTIFIES TIC BELOW TO BE A TRUE COPY OF THE OR/G/N& �% AN SERVICES
<br />WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST l --3VWX / IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. y�
<br />DATE OF ISSUANCE ,
<br />Ann 200007010 }
<br />LINCOLN E RASKA HEALTHA b TEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HOMAI `^ r
<br />�?[NILNC&AND SUPPORT
<br />VrrAL STATISTICS -
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<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SE -- x
<br />3. DATE OF DEATH /MOnm Day Yearl
<br />Elmer William Petzoldt
<br />Male '
<br />April 7, 2000
<br />4 CITY AND STATE OF BIRTH Wricitin USA.. namec nt
<br />ou ry/ 5a. AGE Last Birthday UNDER I YEAR UNDER t DAY 6. DATE OF BIRTH IMo ith. Day Year/
<br />St. Libory, Nebraska (yrs) 81 Sb MOS DAYS 5' . HOURS MINS July 30, 1918
<br />1 SOCIAL SECURTIY NUMBER Its. PLACE OF DEATH -
<br />506 -46 -2429 HOSPITAL. Inpatient OTHER Nursing Home
<br />- - -- —_
<br />8b. FACILITY - Name (lt not instlaraow . give street and number) ❑ ER Outpatient ❑ Residence
<br />Tiffany Square Care Center ❑ DOA ❑ Other,Specily
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />M
<br />S
<br />Grand Island
<br />Yes No
<br />a °.,-�.`.- �...'""n"`"F.-�._,,.,, ,e.
<br />9a RESIDENCE -STATE
<br />7Hall Y
<br />'
<br />9d. STREET AND NUMBER /loc/ding Zip Code)
<br />Nebraska
<br />Grand Island
<br />2309 W. 4th St. 68803
<br />Yea No ❑
<br />10. RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY Is g. Italian. Mexican. German, etc 12. a MARRIED ❑WIDOWED 13 NAME OF SPOUSE 111 w!e grve maiden name/
<br />ISDecdy)
<br />__.
<br />S In
<br />a EIP tIly oG$ adarye1012) College it 4 or 5•i
<br />I�
<br />Farming Agriculture
<br />76. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
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<br />18. WAS DECEASED EVER IN US ARMED FORCES? 19a. INFORMANT - NAME - - - -- -
<br />(In
<br />_ —
<br />19b NFORMANT MAILING ADDRESS (STREET OR R .D NO.. CITY OR TOWN. STATE. ZIP)
<br />215 Sunny Dr., DGni han Nebraska- 68832
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<br />Bwial Removal Memorial Fark
<br />FUNERAL HOMEf AME LI
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<br />Livin ston- Sondermann F.H.
<br />❑cremation ❑Dona"°^ Grand Island, Nebraska
<br />221, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />_
<br />23 IMMEDIATE CAUSE TENT ONLY ONE CAUSE PER LINE FOR lal. (b;. AND (cl Interval between onset and d'eallr
<br />PART / �/
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<br />(c)
<br />ER SIGNIFICANT C05NOITIO itions contributing to the death but not related PART
<br />PARP97
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />q PREGNANCY
<br />8 �/ �C_
<br />rte;
<br />EXAMINER OR CORONER?
<br />a,�
<br />(Ages /0 -54) Vas No
<br />Vey No
<br />Yes D No
<br />26a
<br />26b. DATE OF INJURY /MO.. Day Yr)
<br />26c HOUR OF INJURY
<br />26d. DFSCRIBE HOW INJURY OCCURRED
<br />Accident Undelermined
<br />,
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<br />Suicide Pending
<br />26e, INJURY AT WORK
<br />N
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide investigation
<br />❑❑
<br />Yes No ❑
<br />27a DATE OF DEATH (Mo.. Day. Yr.)
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<br />2 the best of m k th occurr at t e e. date and place and due to the
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<br />28e. On the basis of examination antl or invesoga6on, In my opinion oeaN occurred at
<br />° o
<br />the lime, date and place and due to the cause(s) stated.
<br />(SI nature a itle L "'^ --^+
<br />)5 nature and Title ►
<br />29 DID TOBACCO USECONTRIB TE TO THE DEATH? 30.a
<br />/
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'?
<br />30.b WAS CONSENT GRANTED'
<br />. A- 1:1 YES NO UNKNOWN
<br />Jz
<br />❑ YES 1 NO
<br />❑ YES NO
<br />31 NA_E AND ADDR S OF CERTIFIER (PH SICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type a P/ v
<br />A` Dr John A Wagoner,MD. Alpha jkrjoet Grand Island,NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /Mo. Day Yr)
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<br />WHEN THIS COPY CARRIES TIE: RAISED SEAL OF THE NEBRASKA HEALTH A- AD_44 -44 SERVICES
<br />SYSTEM, R CERTIFIES TIC BELOW TO BE A TRUE COPY OF THE OR/G/N& �% AN SERVICES
<br />WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST l --3VWX / IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. y�
<br />DATE OF ISSUANCE ,
<br />Ann 200007010 }
<br />LINCOLN E RASKA HEALTHA b TEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HOMAI `^ r
<br />�?[NILNC&AND SUPPORT
<br />VrrAL STATISTICS -
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<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SE -- x
<br />3. DATE OF DEATH /MOnm Day Yearl
<br />Elmer William Petzoldt
<br />Male '
<br />April 7, 2000
<br />4 CITY AND STATE OF BIRTH Wricitin USA.. namec nt
<br />ou ry/ 5a. AGE Last Birthday UNDER I YEAR UNDER t DAY 6. DATE OF BIRTH IMo ith. Day Year/
<br />St. Libory, Nebraska (yrs) 81 Sb MOS DAYS 5' . HOURS MINS July 30, 1918
<br />1 SOCIAL SECURTIY NUMBER Its. PLACE OF DEATH -
<br />506 -46 -2429 HOSPITAL. Inpatient OTHER Nursing Home
<br />- - -- —_
<br />8b. FACILITY - Name (lt not instlaraow . give street and number) ❑ ER Outpatient ❑ Residence
<br />Tiffany Square Care Center ❑ DOA ❑ Other,Specily
<br />8c CITY. TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH -
<br />Grand Island
<br />Yes No
<br />a °.,-�.`.- �...'""n"`"F.-�._,,.,, ,e.
<br />9a RESIDENCE -STATE
<br />7Hall Y
<br />9c CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /loc/ding Zip Code)
<br />Nebraska
<br />Grand Island
<br />2309 W. 4th St. 68803
<br />Yea No ❑
<br />10. RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY Is g. Italian. Mexican. German, etc 12. a MARRIED ❑WIDOWED 13 NAME OF SPOUSE 111 w!e grve maiden name/
<br />ISDecdy)
<br />etc.) (Specify)
<br />White American NEVER DIVORCED Ruby Marie Spiehs
<br />MARRIED
<br />_
<br />laa USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed)
<br />of worlung lots. even it retired)
<br />a EIP tIly oG$ adarye1012) College it 4 or 5•i
<br />I�
<br />Farming Agriculture
<br />76. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Ernest ' "aE � � a
<br />18. WAS DECEASED EVER IN US ARMED FORCES? 19a. INFORMANT - NAME - - - -- -
<br />_
<br />(yes no or unk.) (if yes. give war and date, of services) - -now
<br />Yes WWII 6- 19-- 1945/8 -26 -1946 Lavern Petzoldt
<br />_ —
<br />19b NFORMANT MAILING ADDRESS (STREET OR R .D NO.. CITY OR TOWN. STATE. ZIP)
<br />215 Sunny Dr., DGni han Nebraska- 68832
<br />�2O E M - SIGNAT 8 L No
<br />2fa METHODOF DISPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME
<br />❑ Apr. 11, 2000 Westlawn
<br />44-
<br />Bwial Removal Memorial Fark
<br />FUNERAL HOMEf AME LI
<br />21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H.
<br />❑cremation ❑Dona"°^ Grand Island, Nebraska
<br />221, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />_
<br />23 IMMEDIATE CAUSE TENT ONLY ONE CAUSE PER LINE FOR lal. (b;. AND (cl Interval between onset and d'eallr
<br />PART / �/
<br />lal
<br />DUE TO, OR AS A CONSEOUENCE OF Inte al between onset and seam
<br />I
<br />(b)
<br />"— --- — - _
<br />DUE r0. OR AS A CONSEQUf,IICE OF- Interval bet.— onset and -1—,
<br />(c)
<br />ER SIGNIFICANT C05NOITIO itions contributing to the death but not related PART
<br />PARP97
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />q PREGNANCY
<br />8 �/ �C_
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />a,�
<br />(Ages /0 -54) Vas No
<br />Vey No
<br />Yes D No
<br />26a
<br />26b. DATE OF INJURY /MO.. Day Yr)
<br />26c HOUR OF INJURY
<br />26d. DFSCRIBE HOW INJURY OCCURRED
<br />Accident Undelermined
<br />M
<br />Suicide Pending
<br />26e, INJURY AT WORK
<br />26f PLACE QF INJURY - At Iw ,farm. street, factory
<br />otllce bmto ng, etc. tSofmyf
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide investigation
<br />❑❑
<br />Yes No ❑
<br />27a DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED /Mo.. Day Yr. i
<br />28b TIME OF DEATH
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<br />27b DATE SIGNED /Mo. Day. Yr)
<br />27c TIME OF DEATH
<br />28c. PRONOUNCED DEAD lMo. Dag Yr/
<br />2Bd. PRONOUNCED DEAD (Hour)
<br />9
<br />r 1 10 2000
<br />7:38am M
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<br />°
<br />° 9
<br />2 the best of m k th occurr at t e e. date and place and due to the
<br />ausel'I stated.
<br />28e. On the basis of examination antl or invesoga6on, In my opinion oeaN occurred at
<br />° o
<br />the lime, date and place and due to the cause(s) stated.
<br />(SI nature a itle L "'^ --^+
<br />)5 nature and Title ►
<br />29 DID TOBACCO USECONTRIB TE TO THE DEATH? 30.a
<br />/
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'?
<br />30.b WAS CONSENT GRANTED'
<br />. A- 1:1 YES NO UNKNOWN
<br />Jz
<br />❑ YES 1 NO
<br />❑ YES NO
<br />31 NA_E AND ADDR S OF CERTIFIER (PH SICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type a P/ v
<br />A` Dr John A Wagoner,MD. Alpha jkrjoet Grand Island,NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR /Mo. Day Yr)
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<br />APR 112000
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