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<br />STATE OF NEBRASKA
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<br />EN THIS COPY' OARR1ES THE:RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW.
<br />A
<br />TRygpogr OF THE ORIGINAL RECORD ON FILE WITH THE NE,SRASKA DEPARTMENT OF HEALTH AND
<br />AN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS '
<br />DATE OF ISS(MNCE.
<br />9/11Q22
<br />INCOLM= NEBRASKA
<br />1' DECEDEN'r'SNAIB
<br />202208500
<br />c
<br />SARAH BOHNENKAMP .'
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES';
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />.MI 'd Last, Suffix)
<br />t ICTtaT t Mwwitl :Z gden;:'
<br />CIAL 1)ER(
<br />8b. FACILU
<br />c•
<br />r
<br />281
<br />R
<br />ER
<br />itytion, give street and number)
<br />5a AGE LastBlfthday
<br />(Yrs.)
<br />•
<br />91
<br />Fran
<br />8c CITY OR TQWN QF DEA.
<br />Grand (star t . t $TJ
<br />Sa RESIDENCE -STA'.
<br />Nebraska'.
<br />8d STREET AE;13) NUM SER:
<br />12748 lit Hvtllr)0 Ro
<br />0a'MARITALSxTATUB AT"
<br />0l/iarrted but separate
<br />11 FATHERS t{AMIE (FIM
<br />i e�naTd A tc(de.
<br />d
<br />(Iniclude Zip Code)
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />3: OATEOff:DEATH (M4; (gay Yr
<br />A1,19601:244621
<br />. 6. DATE OF:BIRTft (•lige; DayC.Yr I
<br />MOS.
<br />DAYS
<br />8a PLACE OF DE .ATN
<br />HOSPITAL j❑ inpatient
<br />ERIOu patient
<br />❑ DOA.,.
<br />9b. COUNTY
<br />Hall
<br />OP.DEATF.I.O Married 0 Never Married
<br />id ed.:: i -r Divorced 0 Unknown
<br />ast, Suffix)
<br />13 E/ER fN U S ARMW FORCES? Give dates of service if Yes.
<br />(Y'es No or uilk) y es :.01103/1951-11 /30/1954
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />OTHER 0 Nuretng,Ho
<br />0 decedent's
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f.ZIP CODE
<br />68883
<br />10b,. NAME.OP SPOUSE {First, " Middle, Last, Suffix) If wife,'4
<br />Barbara J Wegner
<br />14a. INFORMANT NAME
<br />David Ogden
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18d CEMETERY, CREMATORY OR OT11E
<br />'Grand Island City Cemetery
<br />17a FUNERAL HOME NAME•ANBD MAILING ADDRESS (Street, City or Town, State)
<br />A fel Funeral:Home, 1123 W 2nd, Grand Island, Nebraska
<br />b„PART(Enterthect itt:ete
<br />12. MO'THER'S -NAME (First, Middle,
<br />Florence E: Potter.
<br />LOCATION
<br />16b. LICENSE NO.
<br />1537
<br />CITY / TOWN
<br />Grand island
<br />Maiden Su.
<br />i4b. RELATION SHip TQDECEDENT
<br />Son
<br />CAUSE OF DEATH (See Instep
<br />IOn$ and examples)
<br />arts• Eweans, iniuriee, or complicationsdhat directly caused the death. DONOT enter terminal events such as cardiac arrest,
<br />ularfibr{Natio4 without showing the. etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines if necessary.
<br />YiMIFD}ATE:CANSE:
<br />alEicungiiination
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />aiemothorax
<br />r:IiNo610E TGL..
<br />in)uty:that hill
<br />is resulting' n deA
<br />DUE TO; OR AS:A CONSEQUENCE OF:
<br />b"'1unt chest wall trauma
<br />alp; ORAS A' CONSEQUENCE OF:
<br />otar`vehicle collision
<br />46. PART!I OT 4ER6NI
<br />81PiCANT.CUNDITION3-Conditions contributing to th
<br />hrootarit guiaJi0
<br />,2O IF;;FEMAL
<br />df d4ta
<br />neltk;butpregetarhtwithina2daveoi;death.nn..
<br />t pregnent� but pregnant43days to 1 year before death
<br />. Unknown f p egnamy ittl the past ye
<br />!a tsATE of dNJURY (Md-
<br />Au' ust 24 :2022
<br />death but not iresultbfg in lite underlying cause given in PART 1.
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />®Accident 0 Pending In'mstigat en
<br />El Suicide Could not be determined
<br />22b. TIME OF INJURY
<br />11:50 AM
<br />21b. IF TRANSPORTATION INJURY
<br />Dnveroperater
<br />0 Passenger
<br />Pedestrian
<br />Other dinecify)
<br />22c. PLACE OF IN4NRY,E4.thOtaa,
<br />Road
<br />274:DESCRIBE HOW INJURY OCCURRED
<br />Motor vehicle collision
<br />$2f tocAT#ON Oh"IAJURY;: STRFET:& NUMBER, APT.NO.
<br />$07 Oleude>RoEt1 Grund IsIa»d
<br />23a..DATE OF. DEATH (Mo., Day, Yr.)
<br />&; Art ust 24i'2022
<br />23b DATE SIGNED (Mo , Day, Y1 )
<br />..: Auddst 25: 2022
<br />cITYITowN.•:`
<br />23c. TIME OF DEATH
<br />01:25 PM
<br />d Tbtbabe6t ofn(Ktutowiedge; death occurredat the time, date and place
<br />'.011:$0)000.3.141901)'steteii. (Signature and Title)
<br />George WoOds. MD:'•
<br />25.. DID TOBACCO 01:0„,,, /NTR(R(7TE TO THE DEATH?
<br />..11:":':::''''' 'fieF:'PROBABLY :I UNKNOWN
<br />2? NAME, f'it.A4D AOARESS bF CERTIFIER (Type or Print
<br />Patrick George Woo s, .MO, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />21c. WAS AN`RUT$Et$'/_P!$
<br />21d WERE pl(1TOPSV
<br />TO COMPL
<br />inti Street; factory, office building, co
<br />VAI
<br />ruction 3
<br />STATE
<br />Nebraska.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME.0
<br />24d. TIME PR
<br />:Dm basis of examination and/orinvesttgation, in my ae inert
<br />tl;a t1me; data and place and due to the"cause(el stated. (8agneture
<br />EATf1.
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES j.,no
<br />210 GIDE
<br />•
<br />e0:D
<br />26b. WAS CONSENT
<br />Not Applicable 1126a h
<br />28b. DATE FILED BY REGISTRAR
<br />August 29, 0022
<br />Yr.
<br />
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