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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 />11/9/2020
<br />LINCOLN, NEBRASKA
<br />2 0 2 010 010r
<br />?`SARAH BOHNENICAMPf
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />19 08159
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the County courtin the county where the decedent resided at the time of death.
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Susan Marie Wertz
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.,;Day, Yr,)
<br />June 23, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., bay,Yr.)
<br />Stromsburq, Nebraska
<br />(Yrs.)
<br />65
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 4, 1954
<br />7. SOCIAL SECURITY NUMBER
<br />505.72-4747
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facf ity
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />1212 N. Custer Ave
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<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 />1212 N. Custer Ave
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />1012. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Richard Blaine Wertz
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />LeRoy Letnburq.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frances Rhoades
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Richard Blaine Wertz
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />1:3 Burial ❑Ovulation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.) ,.
<br />June 26.:2019
<br />kl Cremation 0 Entombment
<br />o Removal ' 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME. NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />>17b. Zip. Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />IS. PART I. Enter the chain of events- dl , injuries, or complicetionsthat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE meal a) Hepatobiliary Carcinoma
<br />disease or eond)tion reaulttng
<br />onset to death
<br />Months
<br />in deadll DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading tothe cause listed
<br />on tine
<br />onset to death
<br />a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter. the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Pancytopenia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:-..
<br />Et Not pregnant within past year
<br />0 Pregnantet time of death ?
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED? ,:..
<br />��7}:
<br />0 YES [if NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />guicide could not ba determined
<br />0 ❑
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />D YES 0 NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF
<br />INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE 2IP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 23, 2019
<br />To be completed by
<br />CORONERS PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 27,'2019
<br />23c. TIME OF DEATH
<br />04:53 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />tad. 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 />Chad Vieth, MD
<br />24e. On the basis of examination and/or Investige Ion, In my opinion death occurred at
<br />the time, date and place and due to the cicada) stated. (Signature and Title)
<br />25. DID TOBACCO USE. CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 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 ° ❑ NO
<br />2/, NAME, TITLE! AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />C
<br />DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 28, 2019
<br />-------28b.
<br />''
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