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<br />NEBRASKA
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<br />STATE OFaNE
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA mix COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICE'S, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />.AA 1E OF'ISSUANCE.
<br />40/12/2022'.::„1
<br />LINCOLN,.NEBRA$I A .
<br />20220816,4
<br />)0441.i? &JJ 151t i.+7, 4i,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1•'DEGEDENT, NAME (First, Middle, Last, Suffix)
<br />i.Sonard M • Litwin
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />1 St GIAL SEL URI r NuMaER
<br />tot 6414 .. "
<br />5a. AGE - Last Birthday Sb. UNDER 1 YEAR
<br />(Yrs.)
<br />76
<br />U
<br />8g,
<br />i E
<br />Bb. FACILITY -NAME (if 'Mit Institution, give street and number)
<br />603 Sherman Ave
<br />8c.'OilY OR TOWN OF -DEATH (Include Zip Code)
<br />brand tsIth 16.8803`
<br />9a. RESIDENCE -STATE ;.
<br />Nebraska
<br />MOS.
<br />8a, PLACE OF DEATH
<br />HOS S Tw TAL © Inpatient
<br />ER/Ou patient
<br />❑ DOA
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />5f41>STREETAgppoMBPIR..
<br />0.03 ShsrtDan A1re R .
<br />itis 14ARITAL$iATU$ATTIMEOF1DEATH Married Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHERS:6101E (first, Middle, Last, Suffix)
<br />Lawrence Michael Litwin
<br />13. EVER IN U S ARMED FORCES? Give dates of Service if Yes.
<br />Was,;$o, or Unk) NO
<br />TH&. 3
<br />18 OD OP DISI SiTI(')N
<br />o Butfat->.;'[3 Donation
<br />J I Oremellonjj Entombment
<br />flRemoval `❑Ct#ie !specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT)J{Nit1, Day, W)
<br />September 27; 202(
<br />6. DATE OF BIFITt tMo., Day, W)
<br />December 24, 1943,
<br />OTHER 0 Nursing Home/LTC
<br />E Decedents Home
<br />0 Other (Specify))_. ._
<br />iltiaoplceFatt#Ny
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />1011 NAME OF SPOUSE (First, ;Middle, Last,
<br />Linda M Houston
<br />14a INFORMANT -NAME
<br />Linda M Litwin
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE
<br />68803
<br />Suffix) If wife, give
<br />12. MOTHER'S.NAME (First, Middle, Maiden
<br />Ernestine.. Joan Badura
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Crematory
<br />17a. FUNERAL=#NOME NAME;AND MA LING ADDRESS (Street, City or Town, State)
<br />Liv)ngston:;Soriiierrrienn Funeral Home 601 N. Webb Road, Grand Island, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />9g, INSibE GrrY #.IAGITS;
<br />'FES ONO '>
<br />14b. RELATIONSHIP TO tiECEt1EN1
<br />Spouse
<br />16c.DATE (Mo. Day Yr)
<br />September St), .20201
<br />17b.Y0ce
<br />68803
<br />CAUSE OF DEATHP(See instructions and examples)
<br />Ia. PART I. Enter the chinoeve `--diseases, injuries, or aompllcations-Umt directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arieet,orvsntricularfibmlation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />0Au5E wino a) Respiratory Failure
<br />didoSse ar candaiph resiilNng
<br />in death) :::.
<br />Sequentiallylinf'condltions, if..
<br />any, -leading to the.Sauae !sated
<br />on linea. .. .....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Congestive Heart Failure
<br />1
<br />C..
<br />I
<br />Exits'the UNDER! Y(NG tTA'030�,
<br />(diseste ar !Nu& that Initiated;
<br />the events resulting in death).-.:.
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />)Aortic Stenosis
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />2 Weeks
<br />PABTitipThERSIONIFIOANT CONDITIONS -Conditions contributing to the death but not
<br />Opo Oiab M attension
<br />res
<br />')ting In the underlying cause given in PART I.
<br />AS MEDICALEXAMINER;
<br />CORONER ('+`O, NTACTEi3
<br />YES' E NO"
<br />20. IF FEMALE:
<br />n Nbt pregnant whhet peat year . -
<br />Pfegnred at tBne ordeattt
<br />❑ I¢ot,pregnat(t% but ptttgnam within 42 days of death
<br />40 pregnant, but pregnant 48. days to 1'. year before death
<br />©. Unknown if pregnatd widtin the put year
<br />2.2a.#SATE OF
<br />URY(Mo Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES ©NQ.
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />❑ Accident 0 Pending Introstigatldn
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f 'LOCATION OF INJURY:': STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September27, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />00t01):i` 8 2020 12:39 AM
<br />23.0, Te the Sect; of my knSwledge, death occurred at the time, date and place
<br />arid: dud to theseuse(s) stated. (Signature and Tale)
<br />Isaac J. Berg: MD
<br />21b,JF TRANSPORTATION
<br />Iff,Drhen/Operator
<br />Passenger
<br />❑ Pedestrian
<br />Other(Speafy)
<br />INJURY
<br />21c. WAS AN AtlTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<br />URY.At home, farm, street, factory, office building, construction site, Oka
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />fid. YES h(£) Q PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />240.
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD ..
<br />sale of examination and/or investigation, In my opNdon death accused: at
<br />data and place and due to the cauee(s)stated. (Signature sdtl'Si9e)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />•
<br />❑YES E. NO
<br />,k7 1N ME, TIT Nb ADI 'ESS SF CERTIFIER (Type or Print
<br />Isaac J: Berg; MD; -729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO p;
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 12, 2020
<br />(.0
<br />
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