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<br />STATE OF NEBRASKA
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<br />WHEN € THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/25/2017
<br />LINCOLN, NEBRASKA
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married
<br />s;- ❑ Marned, but separated; ❑ Widowed ❑ Divorced ❑ Unknown
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<br />201704905
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
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<br />STANLEY S. eOOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />lob. NAME OF SPOUSE (First, Middi3, Last, Suffix) If wife, give maiden nar
<br />Donald C Enck
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Elizabeth A Enck
<br />4. CITYANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -34 -5172
<br />811. FACILITY -NAME (N Pot institution, give street and number)
<br />Wedgewood Care Center
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<br />• 9d. STREET AND NUMBER
<br />• 714 N Pine St
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />82
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 8, 2017
<br />May 29, 1934 J
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9G. CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS-
<br />® YES ❑ NO
<br />0
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Manfred Dittman
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />❑ Burial `❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal j❑ Other(Specify)
<br />18. PART'. Enter the chain of events -- diseases, injures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Me. Add additional lines R necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />APPROXIMATEINTERVAL
<br />onset to death
<br />1 Day
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livinaston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island. Nebraska
<br />in death(
<br />' Sequentially list conditions, if
<br />any, leading to the cause tisfed.:
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or lnjury:t 5t. initiated:
<br />the events resultutigm death(
<br />LAST _
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Notpregn, b
<br />antut pregnant within 42 days of death
<br />D Not pregnard, but pteLrnant43 days to 1 year before death
<br />❑ Unknown if pregnant VwithIit the past year
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22d. ( NJURY ATINORIC? .
<br />YES O NO
<br />2 a. DATE Of DEATH (Mo., Day, Yr.)
<br />a April 8, 2017:
<br />13 a
<br />23b. DATE $(t$WD (Mo:, Day, Yr,)
<br />§ u o April 10, 2017
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<br />26a REGISTRARS SIGNATURE
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />22b. TIME OF INJURY
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />• Isaac J. Berm. MD
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Sophie Beyersdorf
<br />14a. INFORMANT -NAME
<br />Donald C !Enck Sr
<br />16b. LICENSE NO.
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hip , Fracture,..AtrialFibrillation, Depression
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ COuld not be determined
<br />23c. TIME OF DEATH
<br />08:30 PM
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<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other(Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />28b. DATE FILED BY REGISTRAI
<br />April 12, 2017
<br />14b. RELATIONSHIP TO DECEDENT.;
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.);.
<br />April 10, 2017
<br />17b. Zip Code
<br />68803
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Dementia
<br />onset tO deat
<br />1 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES j NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />• 'I EC 0 ht/'
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN STATE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death Occurred at
<br />the time, date and place and due to the cancels) stated. (Signature and Title)
<br />25. DID TOBACCO USE Ct NTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES RI NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E] NO Not Applicable if 26a Is NO ❑ YES ❑ '
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
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