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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Christian NMN Wicht <br />2 SEX <br />male ' <br />3. DATE OF DEATH /Month. Day Year/ <br />February 18,2001 <br />4 CITY AND STATE OF BIRTH III not m US. A.. name country) <br />Duff, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) 86 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year) <br />September 12, 1914 <br />01s. MOS. 1 DAYS <br />Sc. HOURS MINS <br />■_ 7. SOCIAL SECURTIY NUMBER <br />508 -16 -5763 <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER iii Nursing Home <br />❑ ER Outpatient ❑ Residence <br />❑ DOA ❑ Other (Specdyr <br />8b. FACILITY - Name /if not institution, give street and number) <br />Community Memorial Health Center <br />27a. DATE OF DEATH /MO.. Day Yr) <br />February 18, 2001 <br />8c. CITY. TOWN OR LtiCATI0N OF DEATH <br />Burwell <br />8d. NSIDE CITY LIMITS <br />Yes No [ <br />8e COUNTY OF DEATH <br />rarfield <br />-I <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Garfield <br />9c. CITY. TOWN OR LOCATION <br />Burwell <br />9d. STREET AND NUMBER (Including Zip Code) <br />925 N. 8th 68823 <br />9e INSIDE CITY LIMITS <br />Yes Fl No ❑ <br />10. RACE - (e.g.. White. Black. American Indian. <br />etc. /(Specify) <br />White <br />1 L ANCESTRY lag.. halian. Mexican, German, etc) <br />ISPecify) American <br />12. pi MARRIED ❑ WIDOWED <br />NEVER DIVORCED <br />MARRIED ❑ <br />13. NAME OF SPOUSE (/I wde. give ma den name) <br />OelSChla er <br />Gladys 9 • <br />14a. USUAL OCCUPATION /Give kind of work done during most <br />1 of working life, even d retired) <br />Postal Clerk <br />14b. KIND OF BUSINESS INDUSTRY <br />U.S. Government <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary 10.12) College 11 or 5•I <br />12 <br />16. FATHER - NAME FIRST MIDDLE LAST <br />f Ferdinand Wicht <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Wilhelmina Seier <br />■ 18. WAS DECEASED <br />(Yes. 0. or unk.) <br />No <br />EVER IN U. S. ARMED FORCES? <br />I 11 yes. give war and dates Of services) <br />19a. INFORMANT - NAME • <br />Gladys Wicht <br />19b. INFORMANT .MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1204 N. Hancock, Grand Island, NE. 68803 <br />20. EMB• 1 ER - SIGN TORE 8 CENSE NO � <br />/ / // / <br />/ / / ( y <br />21a. METHOD OF DISPOSITION <br />X Burial ❑ Removal <br />❑ Cremation ❑ Donators <br />21b. DATE <br />Feb. 22; 2001 <br />21c. CEMETERY OR CREMATORY NAME <br />Rosedale Cemetery <br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Rosedale, Nebraska <br />22a FUNERAL OME . NA 3 C <br />Apfel- Butler - Geddes <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 ONLY ONE CAUSE PER LINE FOR i al Ibl. AND Icl) Interval between onset and death <br />a PART �^ <br />I la) 66/ ,.' o 1.--r„,.// .4 GAD , /' D b3 o . <br />(0) <br />OTHER SIGNIFICANT CONDITIONS - Conditions co ntributing to th e de but not related <br />PART <br />II <br />PART I I I IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 M ONTHS <br />(Ages 10 -54) Yes I I No / <br />.24 AUTOPSY <br />Yes ❑ No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER <br />Yes ❑ Noj <br />26a. <br />. Accident III Undetermined <br />Snide . Pending <br />1 Homicide Investigation <br />26b. DATE OF INJURY (MO. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY CURRED <br />26e. INJURY AT WORK <br />yes No <br />❑ ❑ <br />264 PLACE mlding, etc. QF INJURY - home, farm, street factory <br />ofllce b pee dy) <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />27a. DATE OF DEATH /MO.. Day Yr) <br />February 18, 2001 <br />i ° <br />r° o <br />¢ ° <br />8 0 <br />B; <br />� <br />28a. DATE SIGNED (Mo.. Day. Yr) <br />28b. TIME OF DEATH <br />M <br />1 8 <br />i 7 <br />27b. DATE SIGNED /MO. Day. Y r ) <br />,,. L / 'ot <br />27c. TIME OF DEATH <br />CL I'h M <br />28c. PRONOUNCED DEAD /MO.. Day. 3c) <br />28d. PRONOUNCED DEAD (Hour) <br />M <br />29. DID TOBA2C0 <br />27d. To the best of my knowledge. death occurr at the time. date and <br />` cause(sl stated. _ <br />I (Signature and Title) pi. <br />USE CONTRIBUTE TO THE DEAT ? <br />❑ YES ❑ NO in UNKNOWN <br />place and due to the <br />30. HAS ORGAN OR TISSUE DONATION <br />❑ YES <br />28e. On the basis of examination <br />ihs the time. date and place and <br />and Title) P <br />N CONSIDERED? <br />NO <br />and or investigation. in my opinion death occurred at <br />due to the causes staled. <br />30.b WAS CONSENT GRANTED? <br />❑ YES / NO <br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type m Prim) <br />Dr. D n StevF 400 S. 23rd St., P.O. Box 330, Ord, NE. 68862 <br />32a. REGISTRAR <br />32b DATE DATE FILED BY REGISTRAR (Mo.. Day Yr.) <br />FEB 2 8 2001 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION WHICH IS., <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - <br />DATE OF ISSUANCE <br />ANIEY S. COOPER <br />ASSISTANT STATE REGISTRAR .' <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM: <br />MAR 2 2001 <br />DUE TO, OR AS A CONSEOUENCE OF <br />• <br />1 <br />(b( <br />DUE TO. OF AS A CONSEOUENCE OF <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />201706289 <br />01 01942 <br />Interval between onset and death <br />Interval between onset and death <br />