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WI41.EN TWS COPY CARRIES THE RAISEi3 SEAL (?F THE STATE OF NEBRASKA, IT
<br />C1.ERTIFIES THE DOCUMENT BELOW TO BE A TRUE CO1.PYf THE ORIGINAL RECORD
<br />ON FILE . WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />��I'll'
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR VITAL RECORDS
<br />DATE DF/SSUgNCE A O Q [� ASSISTANT STATE REGISTRAR
<br />�j v v
<br />11
<br />12/6/2016 I 11 DEPARTMENT HEALTH AND
<br />_1. HUMAN SERVICES
<br />LIIVCQLN, NES: :11. A STATE OF NEBRASKA - DEPARTMENT OF HEALTRAND HUMAN SERVICES
<br />16 09864
<br />CERTIF..ICATE::O� q�EATH
<br />1. DECEDENTS•NAME (Firs; Middle, Las; Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />.
<br />Gerald Walter `Gewecke
<br />Male
<br />November 21 2016
<br />CITYAND STALE QR TEI;RITORY, OR FOREIGN COUNTRY OF BIRTH
<br />50L AGE -Last Birthday
<br />St .UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH{Mo., Day'.:.. . .
<br />IYfB•1
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Kearns Nt3braska''
<br />82
<br />Jol 12 "(934
<br />7. SOCIAL SECURITY NUMBER 8a.
<br />PLACE OF DEATH
<br />505-3$-7463,
<br />HOSPITAL inpatient OTHER ❑ Nursing Home/LTC ❑Hospice Facility)
<br />.
<br />89 FACILITY NAME (kf ttot IKistltutlon, give street and number)
<br />❑: Ett/Outpatlent ® Decedents Home
<br />.
<br />413E .12th -.Street
<br />❑ D"OA [Other (Specify)
<br />W
<br />8C. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. C:UNTY OF DEATH
<br />Wood River,: 68883 _
<br />Hull
<br />90. RESIDENCE STATE
<br />9b. COUNTY
<br />8G CITYORTOWN.
<br />:a
<br />Nebraska
<br />Hall
<br />Wood River
<br />LL
<br />d STREET AND NUMBER e. APT. N 9f.
<br />ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />a,
<br />413E 12th Street
<br />68883
<br />[@ YES; ❑ No
<br />a
<br />19a MARITAL STATUS AT TIME OF DEATH ®Married ❑Never Married
<br />10b. NAME OF SPOUSE (Firs; Middle, as; Suffix) If wife, give maiden name
<br />❑Marietl butseparated ❑Widowed [Divorced [Unknown
<br />DonnaSheeks
<br />41, FATHER'S -NAIVE 0-W." Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (Firs , Middle, Maiden Surname)
<br />d
<br />Walter Gewecke
<br />III
<br />Vera Byers
<br />D
<br />13 EVERIN U S ARMED FORCES9 Give dates of service if Yea.
<br />14a. INFORMANT -NAME .
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes No, or Urtk 1 Na
<br />DonnaGeweCke
<br />SPOUSe
<br />II
<br />15 METHODOF:AI$POSIIION
<br />16a. EMBALMER SIGNATURE 16b.:LICENSE
<br />NO.
<br />16c. DATEjMo., Day,'Yr.)
<br />ia-
<br />❑ Suit i b Donafion
<br />,:"
<br />" Christopher J. Loecker
<br />1421
<br />November 26, 2016
<br />® Cremation [Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal :Q Other (Specify)
<br />',
<br />Central Nebraska Cremation Services Gibbon Nebrask8
<br />.: FUNERAL 0.0ma NAMB"AND MAILING ADDRESS (Street, City or Town, State}
<br />17b. Xjp Cods
<br />Agfel Funeral Home, 1123 W.'2nd. Grand Island. Nebraska "` -
<br />68801
<br />CAUSE SE OF DEATH i . ru n d exam le '
<br />4g.PAR7i E; t6eeh= prevents--0iseases, Injuries, or complications -that directly eausedehe death. DO NUT enter terminet events such as caroiac arrest, : APPROMMATS;INTERVAL%:.
<br />re$puatdry artes; or vBMrtt der fibrillation withoutshowing;he etiology. DO NOT ABBREvf1iKE Enter only one cause on i line.: atldkional linea N necessary.
<br />IMMEDIATE CAUSE: onset to t1e8lh .
<br />IMMEDIATE CAUSE�(Final� a)Respiratory Failure . Minutes
<br />'
<br />dlseaae'or condition resuxh+g
<br />Aftdeath) :::;:.DUE TO, AS A CONSEQUENCE OF: ; W death --
<br />.
<br />Sequa elegy list eondttio»s, 3 : b)CardfacArrest ;Minute#
<br />„t
<br />any, v¢8dinfto thtiaause listed >, "' ,"
<br />.on linea. ""
<br />DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE C) :
<br /><:
<br />:(disease orktjury that InNfat>xd;:: ";. ..
<br />rrr
<br />9re averts rasuNl0y lb dean+) DUE TO, OR AS A' CONSEQUENCE OF: onset t0 deatit
<br />LAsr; d1
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />810ad Clots And P16Ur@I Effusion
<br />OR CORONER CONTACTED?
<br />®YES ❑ NO' .
<br />W
<br />IF F.EMALE
<br />21a. MANNER OF DEATH
<br />?1It IF TRANSPORTATION INJUR
<br />21c. WAS AN AUTOPSYPERFORMED4
<br />'
<br />,..P
<br />..❑ Not pregnork-i"hir past year
<br />21 Natural. ❑ Homicide :'
<br />❑ orrverloperator
<br />,IIIII
<br />❑YES ® NO "
<br />"
<br />tWJ
<br />❑ Pregnant at time of death
<br />❑ Accident ❑ Pending investigation
<br />❑ Passenger
<br />`
<br />N4LpfagneM..hut pregnant within 42 days of death
<br />Suicide Could hot be determined
<br />❑ ❑
<br />❑ Pedestrian.
<br />21d. WERE AUTOPSY FINDINGS AVAILABt,
<br />DEATHr
<br />xt
<br />Nut pregnerR,.qut pfLFgpafd,4.3 tlays tot:year before death
<br />",
<br />❑ other ISpeciry)
<br />TO COMPLETE CAUSE OR .
<br />❑ disk»ownttpiegnant wdh1. Me past year
<br />_ " :.
<br />❑YES ❑ r... ,..
<br />E
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />u.
<br />.
<br />22tl. INJURY ATetVORK3 ;'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑YES ❑NO
<br />22f. LOCATION OF INJURY"- STREET & NUMBER, APT.NO. CITYfMWN STATE ZIP CODE "
<br />23a. DATE OPDEATH (Mo., Day, Yr.)
<br />z 24a. DATE SIGNED (Mo., Day, Yr.) 24b.
<br />TIME OF DEATH
<br />a
<br />.. ,
<br />November 23, 2016
<br />Apprax. 92;45 PM
<br />I23b
<br />DATE SI... cN (Mo., Day; Yr.)
<br />23c. TIME OF DEATH
<br />�;!
<br />g a 24c. ['RONOUNCED DEAD (Mo., Day, Yr. Z4d.
<br />TIME PRONOUN .ED DF.s44
<br />o z
<br />j
<br />$ November 21 2016
<br />i
<br />01:05 PM
<br />03d
<br />To the best of myknowletlge, death occurred at the time, date and place
<br />W 24e. On the basis of examination and/or imastigatbn, in my opinion death oeeurtedal
<br />A
<br />and due to the causes) stated. (Signature and Title)
<br />8 0 the time, date and place and due to the causes) stated. (signature anTNN)
<br />Megan Alexander, Hall Deputy County Attorney
<br />:
<br />25. OtO. TOBACCOiUSE CONTRIBUTE TO THE DEATH?
<br />""
<br />26a. HAS ORGAN ORR TISSUE DONATION BEEN.` CONSIDERED?
<br />26b. WAS CONSENT GRANTM).
<br />LINES - Nd-$:tPROBABLY ®, UNKNOWN
<br />❑ YES g NO
<br />Not Applicable if 26a Is NO '' ❑ YES ❑ NO -'
<br />.,
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />o
<br />M' an Alexander, Hall Depu#y County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 ;
<br />28a REGISTRARS SIGNATt1RE /l i 28b.
<br />DATE FILED BY REGISTRAR{M9y Day�Yk.
<br />/L.J�,
<br />.. .
<br />November 30, 2016
<br />}&
<br />M
<br />.
<br />... . _
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