|
I,i,111S3Daav
<br />STATE OF NEBRASKA
<br />sxilliltlt)0))s��
<br />WHEnr= TN15; ":<' COPY CARRIES THE RAISE:; SEAT' l f= .THE :STATE OF NEBRASKG4,
<br />;';CERT[FIES `. THE DOCUMENT BELOW TO Brt ::A TRUE COPY; OF THE ORIGINAL RE
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, P 7AL
<br />RECfaR!?$ pfiFICE, WHICH IS THE LEGAL DEPOSITORY.FOR; VETAL;RECORDS
<br />DATE OF ISSUANCE
<br />4 ;DIT1(ANO;5TAT6 ©it:'llfRlll
<br />Lino Ne fRsk .
<br />tT. DIAL SECURITY NI)MSEI
<br />.:..54 8-603f}
<br />sf . e 'FADIUizy41/ 1- (If 1#el-:Ii ttbltian, viva
<br />CHI Health St, Frp:nDis
<br />a
<br />mot. DECEDENT$ NAME (Irst, �Miii., Lab _ Sulfia)
<br />Violet qernIce Winfrey
<br />Y, QR FQREIQN CQUNTRIF OF BIRTH
<br />r a. OITY OR TOWN OP DEATH finale* Zip God!)
<br />Grand. island..; 088.03
<br />$l.: IRENQIEi7'iAT
<br />number)
<br />lb.COUNTY
<br />11d. ITREETAND NUMisiEST
<br />8; Vyhst ¢th. Street . .
<br />7par. MARIT. u, STATUS'A t TIME OP DEiATH Married © Now Married
<br />MarrIti4kfilei<Q Mewed (� Divorced p Un
<br />known
<br />1. PA1'ii5121.N AMa (First, Middle, Last, Sunda)
<br />Clyde Luthultz
<br />,EVER::IN>U.a.:A.MED PORE
<br />1Yti Na''ac klnbG) O ...
<br />t. METH!OD:OF OISPOSmON
<br />® Bii$hl 1 Dori fore
<br />p Cremation [� Entombment
<br />sernoYPi kor'( Ile)
<br />e dabs of sondes If Vas.
<br />LIMN
<br />•` 7/24/ O19 •' 0 0 2 5 0 4 6 3 . ASSISTANT STATE
<br />/nrcocnr, NEBRASKA DEPARTMENT or HEAL
<br />LI N :..:....AND HUMAN SERVICES
<br />STATE OF NP1BRA$KA • 011P? T ENT:OF N.047 :ANO.I4UMAN $IRVIC88
<br />CERTIPICATEgoo ;DEATH
<br />41, e0 I4aat:lllitli
<br />lyre;)90
<br />MOS,`:
<br />AR
<br />DAYS
<br />a.. PLACE OP DEATH
<br />!!Q$PITAL SI Inpatient
<br />;Q:ERlOul tlant
<br />DOA::
<br />1.45k
<br />Female
<br />ig, UNOER 1 DAY -
<br />Nooks
<br />MINA,
<br />.A DATE QP 041f
<br />JulY1,4t91,
<br />R Q Nurelna 11ontlll.i0
<br />0 DtwsdenFe Home
<br />G7 clew (apselty)
<br />so. COUNTY OF`121ATFJ
<br />Hall
<br />•10b. NAME or..8ROU..le (Flr ..:; Mllddia,
<br />t Wi" 'W rif ty
<br />12 MQTHERia•NAMl (FIn6 Middle, MaN
<br />Vanua Owen
<br />14e, INFQR.MANT.NAME
<br />Dovle - ntreV.-.
<br />e. YMEJALMER.SIGNATURE
<br />Stacie L Ruiz
<br />16q. CEMETERY, CREMATORY OR OTHER 1 QCATION
<br />Wlestlawn Cemetery
<br />ITS. FUNERAL HOME NAME AND MA UNG ADDRESS IStnat City or Tawn, etat$):
<br />All Faiths Funeral Home. 2929 3, Locust Street. Grand Island. Nebraska'
<br />1114. LIDOS
<br />1495
<br />0.
<br />IT'r I TOWN
<br />Grand Island
<br />anplkatlln 4h t directly aluaSd:t o dear , DO Harm
<br />ila phfltatian wdttwut ahawlne the etlaloay. DO NOT ADION Vl*?E. Enter amy.oir ai
<br />IMMEDIATE CAUSE:
<br />CAUap (Final a) Urosepsia, myocardial Infarction
<br />ndNlon nt.ull1np
<br />*?nl+liy leas MineUuhr
<br />any,'Igdine tot rtonsa Hat...
<br />TO. OR AS A CONEEOUENCE OF:
<br />Urinary Tract Infection,
<br />' out Tb, OR AS A CONSEQUENCE OF
<br />Inter IA. UNOIAVinniG GAdid 4)
<br />#�)aq.,w::4r u(brry rauil;lanlN�a;::;:
<br />!I» .tally nlypienu In.trl..Mih)
<br />RT II. OTHERS( ONIWICANT OONDITION$.
<br />der SMITS, HYDSOVraldisnl
<br />25.IP'FE$ALE::....::: _ r
<br />04011anttlthl111aef year
<br />Mat tans of death
<br />rank: tee pn..latore 3Wtliti sa days at path
<br />iMSllia t Nt an*** M deya te *veer Wont death
<br />If aialfttiN:'wlilili 1ba Deer year
<br />It'
<br />22a. DATE OF INJURY
<br />- IN ItJRY AtWC RK?
<br />2f. LOCATION OW INJURY. STREET
<br />y,Yr.)
<br />UENCE OF:
<br />tine to
<br />g,8ar�nTea1 ,
<br />1:••••lnIl such es await Nast,
<br />anal hni , Add addthanel dna* It naarsMry.
<br />•
<br />death but not r autthiti In the undertyin! ea
<br />2r1 1�a. MANNER OF DEAH T
<br />W Natural © Hatt k
<br />Acaidant DandiIDlnveatiletlln
<br />0�•lutcldr Q Qauld;nieka: sin,ined
<br />22b. TIME OF INJURY
<br />NUMIE
<br />it :DATE Of DEATH IMo„ Day, Yr.)
<br />4uly 14 <20t 1
<br />DATE SIGNED (Mo„ Day, Yr.) 220, TIME OF DEATH
<br />July 18.2019 08:25 AM
<br />ad. To the •Ha of my knowledge, Math occurred at the tone, date and Mese
<br />and the to the auntie) data/. (Mlenetgn and TWO
<br />ne AMcDonaldmottOnald, MD
<br />nlnP
<br />1tiq:11: TRANSPOR1iATION iNJUR
<br />r#rl':Itrloaeratar
<br />Iaaseneer
<br />thwti:INan
<br />CI: titlNf (8e•<Uyi
<br />lac. PLACE OF INJURY -At home,
<br />IOWOCCURRED
<br />APT,NQ, CITY/TOWN
<br />11:1
<br />:.:i:::'''.:!:% .:
<br />aL.
<br />fa
<br />, oRIOi b
<br />STATE
<br />Ts)
<br />1
<br />O., tltiflei '
<br />1:APP*O ROM
<br />'owe eikeini'
<br />less thanT2 Hours
<br />'R�rlyteli;la(l>
<br />Qays}
<br />S::aiQNE 24, TIME OI DEATH::
<br />24Q PRONOUNCED DEAD (Mo., Day, Yr) 4d TIMS P ON U
<br />34e, DAT
<br />O (Mo., Day, Yr.)
<br />NC
<br />Ida. On the twat of sa/ndnaeon andtor arwetgaeon. ii cry aslel•n ds It MawI
<br />the tine, date end pion and dye to the aeua ts) stated. teisnowe snd Iwo)
<br />. DID TODACG{=:iUS '4` 7NTR14UTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN'CONSIDERED?
<br />0 YeaAM1 NO PRO5Aat.Y 0 UNKNOWN 0 YES El NO
<br />Ir.NAME, TITLE ADO EMS OF CERTIFIER (Type or Print
<br />Jane A. McDonald; M©, 800 N Alpha Street, Grand Island;; Nebraska,. 68803
<br />REGISTRAR S SIGNATURE
<br />ONEE
<br />Not ApPiEAabh WWI Is NO
<br />21b. DATE FILED or R
<br />July 17, 2019
<br />*A,
<br />
|