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rke A WXXESOINK ex '4.6 STATE OF NEBRASKA walk 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 OF ISSUANCE 201706290 2/23/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gladys Lorraine Wicht 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Harland; Nebraska; 7. SOCIAL SECURITY NUMBER 508 -14 -6360. 8b. FACtLlTY -NAMtc (If not Institution, give street and number) CHI ;Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 RESIDENCE -STATE Nebraska 9d. STREET AND NURSE 1204 N. Hancock Avenue 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, butseparated:! E Widowed 13, EVER IN. U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO $. METHQD OF DISPOSITION E Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting in death) $egoer tially list conditions, if any, leading to the cause fisted on line a. Enter the UNDERLYING CAUSE ((,Eisease or iaiury that initiated';,_ the events tesulting:in death) LAsr .. ... _.. 22a. DATE OF INJURY (Mo., Day, Yr.) Zd. AT,WORK? D YES ❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) February 8, 2017 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Divorced LJ Unknown 16a. EMBALMER - SIGNATURE Christopher J. Loecker 16d. CEMETERY, CREMATORY OR OTHER LOCATION Rosedale Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska IMMEDIATE CAUSE: a)Acute Renal Failure DUE TO, OR AS A CONSEQUENCE OF: b)Urinary Tract Infection With Sepsis DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) O. IF: PEMALE: ❑ Not prognantwahin past year ❑ Pregn at time of death. ❑ Not preanant, but pregnant within 42 days of death 11 Not pregnant,but pregnant.43 days to 1 year before death ❑unknown if pregnant within -the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 14a. INFORMANT -NAME Linda Fryzek 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN $b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH Fe,ruar 9 2017 08:04 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Fruehl MD 5a. AGE - Last Birthday (Yrs.) 94 b: UNDER 1 YEAR MO$. DAYS 8a. PLACE OF DEATH HOSPITAL rn Inpatient ❑ ER/Outpatient DDOA 9c. CITY OR TOWN Grand Island 9e. APT. NO. 11. FATHER'S-NAME (First, Middle, Last, Suffix) William Oelschlager CAUSE OF DEATH (See instructions and examples) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ( NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehlin.., MD, 2116 W Faidley #400, Box 9802, Grand Island Nebraska, 68803 8a. REGISTRAR'S SIG 2. SEX Female HOURS 16b. LICENSE NO. 1421 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Christian Wicht< E; 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margaret Frese CITY / TOWN PART 1. Enter the Chain of events- -diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventneular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 3. DATE OF DEATH (Mo., Day, Yr.) February 8, 2017 April 17, 1922 6. DATE OF BIRTH (Mo., Day, Yr.) n Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DEC EDENT Daughter 16c. DATE (Mo., Day, Yr.) February 13, 2017 STATE Nebraska 17b. Zip Code 68801 APPROXIMATEINTERVAt onset to dent# 3 Days onset to dea 3 Days onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21�b� W TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? U Driver /operator ❑ Passenger ❑ YES ENO ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ATURE STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DE 24e. On the basis of examination and /or Investigation, m my opinion .watt .c;urrae: at the time, date and place and due to the cause(s) stated. (Signature and Title) 28b. DATE FILED BY REGISTRA February 10, 2017 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES,' ❑ NO