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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT l ,
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE,, KkLIAAR
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ,o' VT(41 RECOi
<br />Amended
<br />DATE OF ISSUANCE
<br />04/02/2014
<br />LINCOLN, NEBRASKA
<br />202404985
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
<br />CERTIFICATE OF DEATH
<br />VICES, IT CERTIFIES
<br />ALTH AND
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Marvin Louis Muchow
<br />2. SEX s ; ; 4'i
<br />Male
<br />DATE OF.DIEATH(Mo., Day, Yr.)
<br />June 4, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE - Last Birthday
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH into., Day, Yr.)
<br />Blue Hill, Nebraska
<br />(Yrs.)
<br />99
<br />MOS.
<br />DAYS
<br />HOURS
<br />MIfS.
<br />April 2, 1914
<br />7. SOCIAL SECURITY NUMBER
<br />508-09-1798
<br />8a. PLACE OF DEATH
<br />Horn& ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />704 West 14th Street
<br />Ile. APT. NO.
<br />Sf. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YE$ CI No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF
<br />Therese Ainanda
<br />SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Bermel
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frederick William Muchow
<br />12. MOTHER'S -NAME (First. Middle, Malden Surname)
<br />Mary Mueller
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service I Yes.
<br />(Yes, No, or unk.) Yes 06/27/1941-10/16/1945
<br />14a. INFORMANT -NAME
<br />Therese Ainanda Muchow
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />El Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Derek Apfel
<br />16b. LICENSE NO.
<br />1240
<br />16e. DATE (Mo., Day, Yr.)
<br />June 7, 2013
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />18d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. ZIP Code
<br />68801
<br />I
<br />CAUSE OF DtATHISee instructions and examples)
<br />To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT aver terminal events such as cardiac arrest,
<br />APP ji OMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one muse on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Arrest
<br />disease or condition resulting
<br />onset to death
<br />Immediate
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b) Pneumonia
<br />any, leading to the muse listed
<br />f onset*, death
<br />Proximal,
<br />on line a DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Congestive Heart Failure Exacerbation
<br />(disease or Injury that initiated
<br />onset to death
<br />Proximal
<br />the events running in death► DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Aspiration
<br />onset to death
<br />Proximal.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Acute Renal Failure & Chronic Kidney Disease
<br />19. WAS MED(CN- SI AMINER'
<br />OR CORONER CONTACTED?
<br />❑ YES (I NO
<br />0. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />❑ Accident 0 Pending investigation
<br />21b. IF TRANSPORTATION INJUR121e.
<br />❑ Driver/Operator
<br />❑ Passenger
<br />WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />❑ Suicide ❑ Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 No
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction eke, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 4, 2013
<br />3
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 6 2013
<br />23e. TIME OF DEATH
<br />05:33 AM
<br />i
<br />< zZ
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />O 9d. To thebest of my knowledge, math occ rred at the time, date and platy
<br />.1and due to the causes) stated. (Signature and Tme)
<br />Michael A. Donner, MD
<br />O
<br />8
<br />~
<br />$
<br />24e. On the basis of examination and/or investigation, in my opinion Math creamed at.
<br />the time, date and plea and due to the cauee(s) sated.ra t(Slgro and. TRW)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26e. HAS ORGAN OR TISSUE D • NATION BEEN CONSIDERED?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN 0 YES ® NO
<br />26b. WAS CONSENT GTTANTELIT
<br />Not Applicable If 26a Is NO ❑ YE C3 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE Jp�9 A y l �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 7, 2013
<br />Amended
<br />06/17/2013 Item 12 corrected maiden name
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