|
6.1 1)
<br />WCi
<br />11 11p
<br />/
<br />Y
<br />0@ s
<br />P I I
<br />1 f n
<br />\ � t
<br />d Y 1«
<br />of I
<br />i I(� f
<br />�, iq' r/
<br />acf44��19
<br />rias.?
<br />16
<br />);y4
<br />1
<br />f
<br />rr ;
<br />t� e
<br />r?
<br />41 I
<br />e),
<br />l)
<br />t M
<br />�e
<br />Jttt�, $ / .
<br />ya �4.� .,J...,.
<br />�li�t;re4 nia r /i Inun�(r\13
<br />t tit t e s iii rr ,
<br />1 \' /s 11e1 1 / 1 .3.
<br />.t NYI � f � 1 Il / \
<br />qIY t 0 I/ r S r 1 11 11 art / r! ,
<br />1 % 1 E(lI dA til\A�llAlle/I //�J .d41 ➢��.I 1 eL,i4G! 111Q.A1Nlllll/ / I �
<br />errte��)) \1luuAt S/(IdAlm�.a��1\If))J t I ..._...�._- ((,eelU\ t, \I)
<br />dJP
<br />OF NEBRASKA
<br />)/,rracativrt Ytrtt7191Af1ftaP..
<br />... ...rte..... _. , ,:
<br />at 1'10
<br />a � trtxr@i1As :` rRrnr,,tA
<br />a4,1l
<br />rlrl�
<br />d
<br />e���%ret r44iyi)1i,`(0i�i�� 1((Ynrvu.a 1%
<br />rettt rWr �lil r nn ll(i(r u n g
<br />)I)Ja� � rrr�..titt a�t,ys
<br />yl 111
<br />13)Nr ;/!(((((r... Les;
<br />n, \\\�yt4t,'r��)))iir�l2it(tt urrP,
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA.: DEPARTMENT OF HEALTH AND
<br />HUMAN: SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUJANC£
<br />202207298
<br />t
<br />i6 rd./d? Ai:e$ itit I4 r/:
<br />SARAH I3OHNENKAMP ( <
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEAL 'f H
<br />AND HUMAN SERVICES
<br />Amended
<br />•
<br />(EEDENrSNAME MFltt, Middle,
<br />Sk`Firley Faye Woiken
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Orleans, Nebraska
<br />7. SDCIAt SECURITY NUMBER
<br />508-32.8502
<br />6a. AGE • Last Birthday'
<br />(Yrs.)
<br />0
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tifan.y. Scware C. are Center
<br />8c CifY ORTQWN OFOEATH (include Zip Code)
<br />Grand Island .8$80.3
<br />9a fkES(DENCE-STATE'
<br />Nebraska, .;
<br />9d STREET AND NUMBER;:
<br />71:8 Sw:eetwood Dr.
<br />9b. COUNTY
<br />Hall
<br />87
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa, PLACE OF DEATH
<br />HOS#ITAL ❑ lipasent
<br />0 ER/outpatient
<br />i❑ DQA
<br />10a. MARITALSTATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />Q Married, but separated E Widowed 0 Divorced ❑ Unknown
<br />FATf18RS NAME (Flrs1 '°< Middte, Last Suffix)'
<br />Alv)n . Steadman`
<br />13. EVER IN U.S ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATft .Mr%•. Gay Yr j
<br />June
<br />6. DATE OF BIRTtt (lo., Day t'ra
<br />January 15`1935:
<br />OTHER E Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />$e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g EN,'S1QE CtTY ymirr, .
<br />'t"ES ❑ .fd0 ..
<br />1011. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Merlyn Wolzen
<br />2. MOTH
<br />Ota
<br />ER'S-NAME (First,Middle,
<br />Kennedy
<br />aiden Surnai
<br />45, ME3HOD QFDi8POSITION
<br />E;;Burtai l� pdnatton
<br />1�: remadof),; ❑ arsom ,
<br />❑ °Removal `. ❑ Outer (specify)
<br />14a. INFORMANT -NAME
<br />Tracey Wolzen
<br />16a. EMBALMER -SIGNATURE
<br />Katie M..Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Minden Cemetery
<br />17a
<br />FIJNERAL,.:HOME NAME AND MAIUNG ADDRESS (Street, City or Town, $tate)
<br />All Faiths imeral t4ome, 2929 S. Locust Street, Grand Island. Nebraska
<br />1Sb. LICENSE NO.
<br />1454
<br />14b. RELATII
<br />Son
<br />HIP TO DECEDENT
<br />16c. DATE (Mp Day Vr.);;
<br />June 17,(2
<br />CITY / TOWN
<br />Minden
<br />CAUSE OF DEATH (See II^tstrudtIone and ex
<br />moles)
<br />IS] PART], Enter the chain M events- -diseases, injuries, Or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />sanatory arrest, or ventrictdar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IM[ FiIATRCAl tte{Final
<br />dlaesee er dtmdtl(eh regtrhtng
<br />in death)
<br />IMMEDIATE CAUSE:
<br />a)Diastolic Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Hy haeaanattons +r: b)Caronary Artery Disease
<br />any;;is' ding 10 the cause
<br />onlin
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ender the UNOEtttYINGGAUSE c)
<br />(disease or Injury that inhleted.
<br />die events resuaing In death) ,:: DUE TO, ORAS A:CONSEQUENCE OF:
<br />LAST: .. .. r�
<br />16 PART' tt O1HERSIG(IFIC.ANTCONDITIONS•G
<br />Chronic Obstructive Pulmonary Disease
<br />eft IF;PEMALE
<br />Plot pi99nafl Hithuxpt
<br />ptageent at mita er Pse
<br />gnant but FtWgneree:;vittdn 42 tlays of cleatt
<br />❑ Not pregnant, but pregnant 46 days to 1 year before death
<br />'APPi
<br />onset 't s deatft:
<br />10 Yeats
<br />�1'74;ZIt:G
<br />8880:1
<br />dations contributing to the death but ttotresu(f
<br />�-! ltnknown u ptegnattf wahtn the past year
<br />22aDAT Et'IF INJURY (Mo; Day, Yr.)
<br />22t INJURY AT WORK?
<br />YES
<br />22e.
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homt.4lde
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />g In the underlying cause given In PART 1.
<br />21b, IF TRANSPORTATION INJURY
<br />DreeadOperator
<br />Passenger
<br />❑ Pedestrian
<br />❑
<br />Other (Specify)
<br />19. WAS NIEDi>:iAI.;:ExAMi!$ipat `
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />21c. WAS AN AUTOPa$Y PERFORM1«k9F
<br />21d. WERE AUTOPSY 1NDINOs AVAILA(lnA
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eh ($pacify) :
<br />SCRIBE HOW INJURY OCCURRED
<br />22f.:LOCATtON OF INJURY -:STREET 8 NUMBER, APT.NO.
<br />rY
<br />$ N
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 13 2022
<br />23b. DATE 81GNEf (Mo., Day, Yr.)
<br />June 16 2022
<br />cITYJTOWN
<br />c. TIME OF DEATH
<br />03:00 PM
<br />3dt l o:Mhs bast Of niy:knowedge, death occurred at the time, date and place
<br />end due ti the causeis) stated. (Signature and Titre)
<br />Tyler J. Vettel, MD
<br />2
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />IJP
<br />24b. TIME OF DEATH
<br />DE
<br />44d.. TIME PRONOUNCED.;:PEAD
<br />24e. On the:binds of examination and/or investigation, in my opinion death occurred et
<br />dui time, date and place and due to the cause(sl stated. (Signature anti tide)
<br />26a. HAS ORGAN:OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ENO
<br />TOBACCO USE QQNTRIBUTE TO THE DEATH?
<br />YES NO ❑ PROBABLY ❑ UNKNOWN
<br />7 NAME,'ImAND A6DRESS OF CERTIFIER (Type or Print
<br />Tyitir J. Vette', MD 2116 W Faidley Ave Ste 400, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE \• �Q
<br />26b. WAS CONSENT GRANTS
<br />Not Applicable if 26a le NO
<br />?
<br />SE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 22, 2022
<br />Amended
<br />7/14/2022 Item 4, "BLANK" To "Orleans.'
<br />
|