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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HE/ILTH A <br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THEA THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VIT , . , �1 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />202110622 <br />LagdLN, NEBRASVKA <br />ASSISTANT -8T 1EREOI$TE1 <br />HEALTH <br />,wTEAA.= <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICBSYNOICB. IEi D LWPOR i <br />VITAL STATISTICS • <br />CERTIFICATE OF DEATk,. ,,,; � ; E 4n- <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />Amelia NMI Benzel <br />2., SEX ..ns,,. "...-.. <br />atF�-t <br />Female- <br />.kTrtiATE OF DEATH /Moret. Day. Year) <br />•I..r <br />November 9, 1998 <br />4. CITY AND STATE OF BIRTH It not 0 USA.. name money) <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY ; ,. R DATE OF BIRTH . (Month. Day Year) <br />- Baltzer, Russia <br />"n1 88 <br />5° MDS. ; DAYS <br />sc.HOURS ; MINS August 4, 1910 <br />r 7. SOCIAL SECURTIY NUMBER <br />.1 506-22-6683 <br />g <br />8a. PLACE OF DEATH <br />HOSPITAL: ❑ Inpatient OTHER: ',Ira <br />❑ ER Outpatient <br />❑ DOA <br />❑ <br />❑ <br />Nursing'Home <br />Residence <br />Other /SPCYYI <br />8b. FACILITY • Name /ano) irs8Av*cn plve aaeel and numne) <br />St. Francis Memorial Health Center <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />November 10, 1998 <br />270. TIME OF DEATH <br />5:32p.5 <br />p. M <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island, Nebraska <br />28c. PRONOUNCED DEAD (MO.. MS Yr.) <br />8d. INSIDE <br />Yea <br />CITY LIMITS <br />j'i No ❑ <br />8e. COUNTY OF DEATH <br />Hall <br />ga. RESIDENCE - STATE <br />Nebraska <br />90. COUNTY <br />Hall <br />Sc. CITY, TOWN OR LOCATION <br />Grand Island <br />94. STREET AND NUMBER (Including Zip Code) <br />1304 N Lafayette <br />9e. INSIDE <br />Y«'1 <br />CITY <br />LIMITS <br />No ❑ <br />10. RA,CE�- (ig,, While. Black. American Indian. <br />'W[11hte <br />11. ANCESTRY le.g.. Italian. Mexican. Garman. Inc) ) /� <br />ISPscM)American Cv <br />12. ❑ MARRIED <br />❑ NEVER <br />MARRIED <br />s•i <br />11"'77 <br />f <br />WIDOWED <br />DIVORCED <br />13. NAME OF SPOUSE /a wHo. any maiden name/ <br />Alex Benzel <br />14a. USUAL OCCUPATION /Gree kind of cork dine during moat Q 1)114b. <br />3 d working laseven if retried, <br />- Housewife <br />KIND OF BUSINESS INDUSTRY 9 10 I <br />[Y <br />Domestic <br />IS. EDUCATION (SPauh only how grsde completed) <br />Elementaryar Secondary 10-12) College 11-4 or 5-I <br />'I 16. FATHER - NAME FIRST MIDDLE LAST <br />Henry Dietrich <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Anna Koehler <br />- 18. WAS DECEASED <br />(Yes. monk.' <br />EVER IN U.S. ARMED FORCES? <br />IC yes. gwe war and dates 01 services) <br />19a. INFORMANT - NAME <br />Gary Benzel <br />19b. INFORMANT MAIUNG ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP( <br />4 - West 9th Grand Island, Nebraska 68801 <br />EM: MER - SIGNATURE 8 LICENSE/ <br />NO. .0 I. ?ti)/ 21 <br />12o. �� `� <br />,L <br />a. <br />E'7 <br />METHOD OF DISPOSITION <br />8.,4, R... <br />21 b. DATEre <br />11-13-98 <br />21C. CEMETERY OR CREMATORY -NAME <br />Westlawn Memorial Park <br />22a. FUNERAL ' • E - NAME <br />Apfel-Butler-Geddes <br />❑ Creon ❑ Donets <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />. FUNERAL HOME ADDRESS (STREET OR RF.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Street Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUSE _ (ENTER ONLY ONE CAUSE PER LINE FOR lel. Ib), AND (C)) <br />PART <br />I <br />(a) <br />.ltrA� <br />DUE TO. OR AS A CONSEQUENCE OF: <br />Ib) 1�tti <br />DUE TO. OR AS A CONS <br />fi,ct,.NdegAtA-46e <br />- Malignant <br />Interval between onset and dear <br />l ��.• - <br />Interval between onset and deem <br />Vl <br />Interval between onset and death <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing lo the dao i tea not related <br />11(Ages <br />PART Ili IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />10-541 Yes ❑_ No <br />24 AUTOPSY <br />Yes l l No <br />y <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER(i►yfw/ <br />Yes I I No J/ <br />26a. <br />• Accident I. Undetermined <br />II Suicide • Pending <br />In Homicide Investigation <br />28b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes ❑ No ❑ <br />261. PLACE OF INJaUdRY `!U torte, farm. street laebry <br />odds busan9 SPeCA'/ <br />26g LOCATION STREET OR RF.D. NO. CITY OR TOWN STATE <br />iS <br />g <br />g <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />9, 1998 - <br />• <br />a <br />28a. DATE SIGNED (Mo. Day. Yr.) <br />260. TIME OF DEATH <br />•November <br />M <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />November 10, 1998 <br />270. TIME OF DEATH <br />5:32p.5 <br />p. M <br />5c ' <br />,n <br />.2M <br />28c. PRONOUNCED DEAD (MO.. MS Yr.) <br />28d. PRONOUNCED DEAD /Hoot <br />270. To the Wet d my knowledge. urred at the and** b the <br />causels) stated. / <br />(Signature and Title) ► J/ I • j't�/ <br />s, 8 <br />28e. On the basis d examination ard'o Mlveatigation, in my opinion death occurred at <br />► the time, date and place and due 10 the cause(' stated. <br />(Signature and Title) ► <br />29. DID TOBACCO USE CONTRIBUTE TO TH TH? <br />❑ YES 10 ❑ UNKNOWN <br />30.a HAS ORGAN OR T E DONATION BEEN CONSIDERED? <br />❑ YES EgiIQ6 <br />30.0 WAS CONSENT GRANTED? <br />• <br />❑ YESTI.N0------- <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type Or Prim) <br />Dr. Daniel R. Cronk 9 North H w d Grand Island, Neb asks 68803 <br />/a��Mo <br />32a. REGISTRAR �32b. DATE FILEI, TIR V <br />