|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA'D HUMAAkVICES.
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THAL, RECORD -61.>£
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V114'ST'
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. 'f
<br />DATE OF ISSUANCE
<br />JAN 10 2006 20 200%4'
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND Hb. MA $�{(1�`ES F1NAfiCEpt 1
<br />C FRTIFI[ ATIF AC•hA7Lt=-
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) i
<br />Patricia Marie Ewoldt
<br />2:-.4A-±= .i3'DICf1rtfFDEATH
<br />Fenale":-
<br />(Mo.,Day. Yr.)
<br />December 27, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Lass Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />a
<br />(Yrs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 6, 1927
<br />7. SOCIAL SECURITY NUMBER
<br />506-26-1709
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient Mg XX.NureingHome/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Wedgewood Care Center
<br />LI ER/Outpatient ❑ Decedent's Home
<br />❑ Dm ❑ Other (Speciy)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska •
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2021 N. Wheeler
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />ID YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH al Married LI Never Married
<br />7 Married, but separated ❑ Widowed CIDivorced CIUnknown
<br />10b. NAME
<br />Dona
<br />OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />1 d .. D . Ewoldt
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Walter Engel
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marie. Hopp
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes,rid,9runk.)
<br />148. INFORMANT -NAME
<br />Donald
<br />D. Ewoldt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />O •:'•
<br />15. METHOD OF DISPOSITION
<br />Burial ❑Donation
<br />16a. E A E SIG TURE
<br />ei
<br />6�
<br />16b. LICENSE NO.
<br />1/ 9/
<br />16c. DATE (Mo., Day, Yr.) -
<br />December 30, 2005
<br />M
<br />❑ Cremation ❑ Entombment
<br />❑Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMA Y OR OTHER LOCATI
<br />Grand Island City
<br />CITY / TOWN STATE
<br />Cemetery Grand Island, Nebraska
<br />t
<br />M�
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S.
<br />18. PART I. Enter the chaln of events -"diseases, Injuries, or complicaticus--thai directly caused
<br />Locust St.,Grand Island,NE
<br />the death, DO NOT ender terminal APPROXIMATE
<br />17b. Zip Code
<br />68801.
<br />INTERVAL
<br />K
<br />11
<br />(
<br />respiratory arrest, or ventricular tibiillation without showing the etiology. DO NOT ABBREVIATE.
<br />fl flY.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Ftnal (a) Y` \'`V (YN 0 (, \ a
<br />events such as cardiac arrest,
<br />I
<br />Enter onlyone cause on a line. Add additional lines if necessary. I
<br />I
<br />onset to death
<br />a9
<br />disease oreoMition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />In death)
<br />Sequentially list conditions, If (b)
<br />leading
<br />I onset todub
<br />k•1:..,,, ,;
<br />< ;,N
<br />any, tothe cause listed DUE TO, ORASACONSEOUENCEOF:
<br />online a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c)
<br />I onset to death
<br />I
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />F `
<br />(d)
<br />onset to death
<br />.":`�:)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />U. �` (\(.'..-.' �`
<br />resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED? �
<br />❑ YES NO
<br />20. IF FEMALE:
<br />Not pregnant within past year
<br />CI Pregnant at time of death
<br />215. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident❑ Pendia
<br />Invest atlon
<br />21 b. IF TRANSPORTATION INJURY
<br />CI Driver/Operator
<br />LI Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES 0
<br />CINot pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />R,
<br />•- ❑ Unknown if pregnant within the past year
<br />❑ Suicide ❑ Could not
<br />be determined
<br />CI Pedestrian
<br />CI Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />orim
<br />i.
<br />11
<br />22b. TIME OF INJURY
<br />22c_PLACE OF INJURY
<br />-At home, term,
<br />street, factory, office building, construction
<br />site, etc. (Specify)
<br />V.; 1: 22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />art! 22f. LOCATION OFINJURY - STREET aNUMBER, APT. NO. CITY/TOWN
<br />�xat.
<br />SIA16 ZIP CODE
<br />a,ptt.
<br /><
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 27, 2005
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />A., z
<br />24b.TIME OF DEATH
<br />m
<br />�.. Ea2
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />L a4' o bQS--
<br />23c. TIME OF DEATH
<br />04:05 am
<br />I ! PC24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />aa4�
<br />Ew z
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />q�O
<br />.E
<br />g
<br />k.; 4
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />ue to the cans aced. (Signature nd TItle) ♦ /�
<br />-- tiNI I n n tAA -- Ii% 1 1
<br />8 w C 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />0 o the time, date and place and due to the cause(s) slated. (Signature and Title ) •
<br />~cal o
<br />. " 25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />❑ YESNO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑YES ❑
<br />27. NAME, TITLE ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John J. Cannella, M.D., 729 N. Custer Ave., Grand Island, NE 68801
<br />1
<br />628b.
<br />28a. REGISTRAR'S SIGNATURE Atkof ,(f .
<br />DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 4.2006
<br />
|