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DOUGLAS COUNTY WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY,' NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY HEALTH DEPARTMENT VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/06/2018 OMAHA, NEBRASKA 20180 73q9 ADI POUR HEALTH DIRECTOR DOUGLAS COUNTY HEALTH DEPARTMENT STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Wayne Frederick Gulzow 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 1, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo Day, Yr.) Grand Island, Nebraska (Yrs.) 86 MOS. DAYS HOURS MINS. March 12, 1932 7. SOCIAL SECURITY NUMBER 507-34-6204 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 9828 Louis Drive 0 ER/Outpatient 0 Decedent's Home 0 DOA E Other (Specify)Brother-in-law'S Home 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68114 8d. COUNTY OF DEATH Douglas 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand island 9d. STREET AND NUMBER 520 Redwood Rd Be. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Angeline T. Buhrman 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frederick Gulzow 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Carolyn Schwieger 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or link.) Yes 09/02/1952-07/02/1954 14a. INFORMANT -NAME Angeline T Gulzow 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 1, 2018 E Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d.CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Braman Crematory Omaha Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Braman Mortuary, 1702 N. 72nd Street, Omaha, Nebraska 17b. Zip Code 68114 CAUSE OF DEATH (See instructions and examples) 13. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the: death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL retpiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line:: Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Undetermined disease or condition resulting onset to death in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if :: b) any, leading to the cause listed on tines. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury Mat Initiated': onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. Gastrointestinal Issues (unspecified) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: El Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural El Homicide Accident Pending Investigation 21b. IF TRANSPORTATION INJURY E3Driver/Operator Passenger 0 21c. WAS AN AUTOPSY PERFORMED? El YES ENO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown Ifpregnant within thepast year El ❑ Could not be 0 Suicide ❑ determined o Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? '. YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY.. ONLY 24a. DATE SIGNED (Mo., Day, Yr.) November 6, 2018 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 1, 2018 24d. TIME PRONOUNCED DEAD 01:43 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 24e. On the basis of examination and/or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title)William Ouren, Acting Douglas County Coroner 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? EYES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO DYES ENO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Ouren, Acting Douglas County Coroner, 1819 Farnam St #909, Omaha, Nebraska, 68183 28a. REGISTRARS SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 6, 2018 A� /. o w