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STATE OF NEBRASKA
<br />OerrAWinm .„.w.,?A955rIYnco tie ...._•"As N av c aorQFGi G I'11�P@bye :' .�rrrJ,gytnt�
<br />WHEN THIS COPY CARNES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMANSERVICES, WTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANt
<br />7/13/2023
<br />LINCOLN, NEBRASKA
<br />20240Q246
<br />0
<br />3,gie
<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. DECEOENT'$:<NAME {INrat, Middle, Last, Suffix)
<br />.0.0nekt William iWitt
<br />2. SEX
<br />Male
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha. Nebraska -<
<br />7 SOCIAL SECURITY NUMBER
<br />505-46-4636
<br />Sb FACILITY -MASSE (if.MUbaaoa; give street and number)
<br />Veterans Affairs Medical Center
<br />8c. -CITY OR TOWN OF DEATH pncludit Zip Code)
<br />incl Island 68883
<br />9a.' RESIDENCE'STATE
<br />Nebraska
<br />I. STREET AND NUMBER.
<br />4209 Kay AYerUe
<br />5a...AGE - Last Birthday;
<br />(Yrs.)
<br />82.:
<br />Sb.`U:NQER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />Ba,PLACE OFDEATH
<br />HOSPITAL � Inpatient OTHER 0 Nursing Home/LTC
<br />ER/Outpatient 0 Decedent's Hoeg
<br />DAYS
<br />HOURS.
<br />MINS.
<br />23 09056
<br />3. DATE OF DEATH (Md
<br />June 2z 2023'
<br />8. DATE OF SIRTH (Neo., Day, Yf.j`
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />10e MARITAL STATIJSATTIME OF DEATH ® Married 0 Never Married
<br />0 Monied, but separated ❑Widowed ❑ Divorced 0 Unknown
<br />• FATHER &NAME #Firs
<br />Willis August filllitt
<br />2
<br />a,
<br />Iddle, Last, Suffix)
<br />ER IN 0 t ARMED:i'ORCES? Give dates of service if Yes.
<br />s, No, arUok.) Yes 12/09/1963-12/08/1965
<br />15.1w OF DISPOSITION
<br />[:Burial ; [] Donation
<br />j Crernadorl:: ❑ Entombment
<br />❑ llamova! ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />❑ Other (Specify) v�
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />9g �ryry INSIDE CITY LIMITS
<br />YEs No
<br />10b NAME OF SPOUSE (First," Middle, Last, Suffix) If wife, give maiden name
<br />Vetta
<br />Miller
<br />I12 MOTHER'S NAME (First,
<br />Loretta Neuhaus
<br />14a. INFORMANT -NAME
<br />Vetta May Witt
<br />8a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />174. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alla Faiths Funeral Home, 2929 S. Lodust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />Middle, Malden Stints
<br />CITY /TOWN
<br />Gibbon
<br />CAUSE OF DEATH':( See: instructions and examples)
<br />14b. RELATIONSINlp'
<br />Spouse . .
<br />18e. DATE (Ma., Day;:
<br />June 26,
<br />ATE.•
<br />1#. PARTS. Enter the Chain of events- diseegs, Injuries, or complications{het directly caused the death. DO NOT enter terminal events such as cardiac erreat,
<br />respiratory arrest, or ventriCtilarfibrillatktn Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pulmonary histoplasmosis
<br />94MEDIATECAUSE(Fktal :.
<br />tliseees or abttd�(,bn rewbinp:
<br />AP
<br />IN AL
<br />Sequentially list conditions, if
<br />any,. Ie ding to the paues listed
<br />on tine a
<br />Enh'tithe UNDERL: NGCAt/8E
<br />Idlaeaes pr trlury:that mewed'
<br />Are events resulting in death)
<br />LAST
<br />DUE' TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic obstructive pulmonary disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />death
<br />anselo di
<br />TO, OR AS A CONSEQUENCE OF:
<br />18 .Pii►RT II OTHEW R SIGNIFFICANT CONDITIONS -Conditions contributing to the death but notresulting it, thetinderlying cause given In PART I.
<br />Goneraiized1fallure Ip thrive, heart failure, coronary artery disease
<br />r 8. IF FEMALE:
<br />Notprapnant'wit in paatyeer
<br />00,„4 tatilne dr deati
<br />'Not itti 9na* but pregont within 42. days of death
<br />© Not Pregnant,: but pregnant 43 days to 1. year before death
<br />0 Unknown tf pregnant Within the past year
<br />22d.1NJURY AT WORK?
<br />OYES [IND,
<br />t7CAT#ON4`�1
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homkide
<br />❑ Accident ❑ PentNlig inveatipstlpn
<br />El Suicide ❑Could not be determined
<br />22b. TIME OF INJURY
<br />21b.•:IF TRANSPORTATION INJURY
<br />❑ prlvaf/0perator
<br />pesPeen
<br />ger
<br />❑.Iaedestrlan
<br />❑
<br />Other (Specify)
<br />19. WAS MEDT
<br />OR COR
<br />O YEs
<br />21c, WAS AN AUTOPSY P1$I
<br />0 YES ®' NO
<br />21d. WERE AUT
<br />TO COMPLETE
<br />DtAWINER
<br />NTACTED?
<br />A LA11:ABI.E
<br />DEATH?
<br />❑ YES 0I,',1
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction
<br />SCRIBE HOW INJURY OCCURRED
<br />NUMSSR, APT.NO.
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 25, 2023
<br />23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH
<br />June 26.2023 05:15 AM
<br />28d. To the test of 510 knowledge, death occurred at the time, data and place
<br />aril due io i1ta:cause(s) stated.(Signature and Title)
<br />Jennifer Kind, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES . Ea NO }PROBABLY 0 UNKNOWN
<br />7. NAME, TITLE AND ADDREs5 OF CERTIFIER (Type or Print
<br />Jennifer King, MD., 2201 N Broadwell Ave, Grand Island, Nebraska, 68803
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24e. Oaths balls of examination and/or Investigation, in ply opinion de.tt. dxeure etF
<br />the teen, date and place and due to Ow cause(s) stated. (aigneltu1* and Tis)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES NO
<br />28a. REGISTRAR'S SIGNAIIJRE
<br />28b. WAS CONSENTGRANT
<br />Not Applicable H 28a is NO t,-1 YE
<br />fir- to i gerstir ter, '1
<br />28b. DATE FILED BY
<br />July 7, 2023
<br />R (Mo., Day, Yr.)
<br />Y
<br />0
<br />W
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