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STATE OF NEBRASKA
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<br />WHEN:THIS COPY 4401ES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EEA TRUE COPY OF'#HE 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 Of ISSUAAt:
<br />1/30/2023
<br />LINCOLN, NEBRASKA
<br />202401311
<br />SARAH BOI{NENKAMP`",
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 DECEDENTS.NAME {Fest, Middle, Last, Suffix)
<br />JOrome :Carl.W rneke
<br />CERTIFICATE OF DEATH
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island,. Nebraska
<br />7.; SOCIAL' SECURITY NUMBER
<br />506.44.3889
<br />Sal AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />FACIUTY-NAMEtIf hot Institution, give street and number)
<br />CHI Healtll:Nebraska Heart
<br />Sc.CITY OR TOWN OP DEATH (Include Zlp Code)
<br />Lincoln 68528: < "`
<br />6a. RESIDENCE -STATE
<br />Nebraska....
<br />Sd, STREET AND NUMBER
<br />4177W Capital Ave'
<br />Ob. COUNTY
<br />Hall
<br />5bUNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8i. PLACE OF DEATH
<br />HO$ PITAt ®1RPatient
<br />0 ER/Outpatient
<br />[] DOA
<br />10& MARITAliiTATUi4triME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />Ii. fATHER'SNAME (Filet, Middle, Last, Suffix)
<br />Carl Wake
<br />13. E•VEK tN•U S ARMED'FORCES? Give dates of service If Yes.
<br />(Yes, No, orlink.) Yes 10/15/1965-08/06/1968
<br />16,METE oOFIJISPOSITION
<br />Burial Cl s#ton
<br />Cremation Entombment
<br />❑ Removai ` ❑Other (Specify)
<br />Sc. CITY OR TOWN
<br />Grand;I.sland
<br />HOURS
<br />MINS.
<br />23 0090.0
<br />3. DATE OF DP.ATH:(Mo., play Yr)
<br />January 21:=:1023::::
<br />6. DATE OF BIRTTr(Mo.,
<br />Octob
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedents Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />Ile. APT. NO.
<br />St. ZIP CODE
<br />68803
<br />5. 1943::
<br />FasDNY
<br />8q INBCrrY(,LMfr8
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden'
<br />Janet Thurber
<br />14a. INFORMANT -NAME
<br />Janet Warneke
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER`S-NAME (First, Middle, Maiden Surname
<br />Cecelia Frauen
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island,': Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />Ii. PART I. Eater the chain Osceola. elteeaees, Injuries, or compiicaaonsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respbatocy arrest, or ventricular fibfleatien without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE cause:
<br />AipietoiATEAning(Ftnal a)Multi system organ failure
<br />ow** or conttt(gn rtacitirty
<br />In &satDUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially lilt conditions, if N) Myocardial Infarction
<br />any,lea ,ytethe::ceuse:unw
<br />on Roe I.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C) .
<br />the events te g„awl." DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST ..... d)
<br />18. PART n. OTHERSiONk
<br />A
<br />20 IF.FEMALE„
<br />�-t Not prag er ant hlM11n )qts
<br />LJ x:
<br />❑.nregneattit Inco dash:'
<br />T CONDITIONS.Condltions contributing to the death but not resulting in the underlying cause given In PART I.
<br />NotPrsgnlliitr butpregitiM within 42 days of death
<br />o Not pregnant, but pregnant 42 *Wit* 1 year before death
<br />D
<br />unknown K;ynanIMMI In the out year
<br />22 ;PATE LIP INJURY Nko ,. bay, Yr.)
<br />22d. INJURY AT WORK?
<br />CI YES .:.❑
<br />21a. MANNER OF DEATH
<br />Natural Homicide
<br />0 Accident ❑ Penteng Invaaligation
<br />0 salads Could❑not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Drltaroparator
<br />>❑ Passenger
<br />QPedestrian
<br />❑ Other (Specify)
<br />14b, RELATION»''r°DECEDENT'
<br />Spouse
<br />16c. DATE tam, Iray, Yr,
<br />January:27,:2!
<br />onset to death
<br />IS. WAS MEINCAt, EXAMINEE;.:
<br />ORCORONERtAO11TACTED? '.
<br />❑ YES ®NO
<br />21e. WAS AN AUTOPSY PERME
<br />❑ YES IZIINOJ
<br />21d. WERE AUTOPSY FINDINGS A{fA1iAS
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YEs 0 No
<br />22c. PLACE;OF INJURV.At home; farm, street, factory, office building, construction sits,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />222 LOCATI01:GPINJURY.+;STREET'S NUMBER, APT.NO.
<br />234. DATE OF DEATH (Mo., Day, Yr.)
<br />January 21, 2023
<br />cITYITOW.N
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 1: 2023
<br />23c. TIME OF DEATH
<br />01;23 PM
<br />Th her but OtMy knowledge, death occurred at the time, date and place
<br />held due to the causes) stated. (Signature and The)
<br />Fernando N Lamounier, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />1> YES I NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD:.:...
<br />142.On tM bsels of examination and/or invsetigalbn, In my opinion death oscuned at
<br />Spk time, data and plata and due to the cause(s) stated. (SNgaattre imd'ftte) ...
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES RI NO
<br />X27 ME, TIT#:£ ;YAMMERS OF CERTIFIER (Type or Print
<br />FeMandtrN LMTlounier, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />28a, REGISTRAR'S SIGNATU
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO OYES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 25, 2023 ..
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