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STATE OF NEBRASKA ),
<br />z.eA4t.1.D� 9%(004111110`
<br />2ittt'/:a'111.1\JtSg>.:>:: c!ITAWIII8
<br />.::,2EG41'Lt9;1:P11it5`;
<br />';►THEN ' T iIS" COPY CARRIES THE RAISED: :,SEAL' OF . <i THE. STATE OF NEBRASKA,
<br />CERTIFIES:: THE DOCUMENT BELOW TO BC:A .RUE COPY.:!:::'OF THE ORIGINAL RE
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY. FOR VITAL RECORDS
<br />r� R
<br />1�WICTA STATE REGISTRAR
<br />DEPARTMENT Or HEALTH'
<br />C N EB AS � �� L� ,<: ::...:AND HUMAN $$RVICES '
<br />'114.AND-HUMAN 3IRVICRR(A
<br />CERTIFICAT < >A' DEATH'.
<br />DATE OF ISSUANCE
<br />7/24tr2 ?19
<br />fN O ..: NEBRASKA
<br />KA
<br />:. O STATE OF NEBRASKA • DEPARTMENT:;OP'
<br />t, 'sums!
<br />Linc t n , fyettalth
<br />g.11041AL SECURITY NUMIER
<br />..-508-2.8 038..
<br />Sb. FAGIL:f?Y.NAME (It not (Mtltutlon, give street end number)
<br />CFi.f hit lalth St F B:ncis
<br />SOWN OP DEATH Ilnaluds Zip Bode)
<br />land... 85.803
<br />Nebtiffigi
<br />9 RE ENOE4T TS' ':
<br />Id. STREET ANDNUMMER'
<br />8;2 West 5th Street
<br />10a. MARit1'AL SIA4TUS;:AT TIME OF DEATH ® Minted Cl Never Married
<br />kHewn
<br />e e
<br />[�:#IRr+isai buS 11 pirateid:i : Q Widowed 0 Divorced CI Un
<br />au. al OR
<br />Grand
<br />la
<br />A1, Felit41 .NAME (Flest;
<br />Clyde Luthultz
<br />1:2 EVaRstN: U.S: ARMED Il
<br />tt»r, Na; 9r yrtfa} : D`
<br />IL METHOD OF?.
<br />® Buda!'
<br />Q Cnrn+auon
<br />11.1.914
<br />Didion
<br />Entombment
<br />ar:Mgr/0y)
<br />Give
<br />lb. COUNTY
<br />HSll
<br />Last, &uMlx)
<br />lee It Yse.
<br />Ott,AGE.:?;ast:Elr#htley•
<br />:1 YEAR
<br />R. SEX
<br />Female
<br />to, UNDER 1'
<br />MOB.:
<br />Ii. PLACE OF DEATH
<br />HOSE PITTAL lnpetlsnt
<br />$
<br />HOURS
<br />MINS,
<br />DATEOF
<br />July 1f,,
<br />F r y '20j
<br />i' _img © Nursling Homo/LYS
<br />:ERJOU00411ant ©Deosd.M'i Henri
<br />604 Other (epeelh)�
<br />id. COUNTY OP DEATH
<br />Hall
<br />9C;C! CY t31x `OWN.
<br />+E3ant �i&I'I�1
<br />If. ZIP CODE IG II
<br />688Q�
<br />:10b, NAME Off SPOUSE (First;::: Middle. List, Suffix) NW*, AIVS$MIUanMEOW
<br />':Di tvly
<br />1t. MOTHER'a•NAME (First Midrib, Metlin Surne
<br />Venus Owen
<br />14a. INFORMANT -NAME
<br />Dpyle
<br />lea. EMBALMER.SIGNATURE
<br />Stacie L Ruiz
<br />W CEM(1TERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />1T11. FUNERAL HOME NAME AND MA LINO ADDRESS (Street, City or Town. Steta)'.
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />r splrul{ rll Sn
<br />IMMEDIATE CAUsC (Final
<br />dieaee or oendhien rife
<br />Eetluiintia1 listeot tieh
<br />lay,'l Stu tcb$tSsiueR:9
<br />en lIns:.;::.
<br />s .:..
<br />inter the 0wos14.Ye10 CAUSE
<br />titleseolttlrinjury obiCIaltfeteti
<br />...the eye* Htetttiultll:lnAnnott,)
<br />So. APT. NO.
<br />:16b;'t.ICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />.CAcisg QF DEM'9JS4 Illa;[+IGtJajt'And QiSarpcfes)
<br />... • illseeso , in)urlea, of cempteadaneehet directly aaua54tiw'dMeah. DO NOT.nlds.tenniri.l evelus such se carols wile,li(ir sins hpn without chewing the stleleey. DO NOT ASIREVIATS. fin*: only 4m Owe on'i1 ibm'Add adahlenel linen If na.aary.
<br />MEDIATE CAUSE:
<br />a) Urosepsis, myocardial Infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />4/Urinary Tract Infection,
<br />Out
<br />a)
<br />OR AS A CONSEQUENCE OF:
<br />DUE, TO. OR AS A CONSEQUENCE OF:
<br />`d)
<br />1S. PART II.OTHER SIGNIFICANT OONDIT1ONE
<br />A+prttaRtie:iiome. I4Ypethyreidlsm
<br />22a. DATE OF IN
<br />YES
<br />LOCATION
<br />4t dee' al Math
<br />le 1 yea h tere death
<br />veer
<br />0htana aontdbutinq to thi ;With but not moulting In the underlyinj ttsstsi
<br />RY (Me„ Day, Yr.)
<br />21e. MANNER OF Dt1AY'H
<br />Natural I:I Nahihti •
<br />Accident 0Sandinglnvesti onen
<br />Q "Weide ©gro it:Cot be ainevillnad
<br />22b. TIME OF INJURY
<br />in In P
<br />me)
<br />1110. DAM (Mo.,'# 0yy
<br />,)Ulv 20, 2010:
<br />AFFRoartastniNTSi
<br />moot to tlrliltri'
<br />less than 79t Hours
<br />tWASM
<br />OR 0#H •
<br />ON !NJU 21i• WAS AN At)•
<br />i P$V hi l
<br />Tif
<br />WERE AU
<br />TO 00MPLa
<br />0 vie
<br />22c. PLACE OF INJURY•At home, farm, almost, factory, onto building, co
<br />El E HOW INJURY OCCURRED
<br />NUMiER, APT.NO.
<br />DAf1t O>=;ISEAt1. (M0,r Gay, W.)
<br />O04'r>209
<br />ATS SIGNED (Mo., Day, Yr.) 220, TIME OF DEATH
<br />July 18. 2019 08:25 AM
<br />230. To the heat Om eneoledis. death occurred et IM Lew, data end pies
<br />and due to the cute(.) stated. (alanstlre end Th41
<br />CITY/TOWN
<br />.STATE
<br />243. DATE:SIGNED (Mo., Day, Yr.)
<br />24a. PRONOUNCED DEAD (M
<br />2
<br />24d, TIME PRONOWl
<br />toe. On the bale of exeaderaon and/or WveelloelNn. In eM
<br />the One. data and pine end dye to the melds) seated.
<br />Jane A MCD7nald, MD
<br />aX DID;1 O>SACC) USE CONTRIBUTE TO THE DEATH? tea. HAS ORGAN::OR ATIONSEENCONSIDERED?
<br />NO PROSASLY UNKNOWN A YES
<br />�Y NAME, TITLE AND ADDRESS Of even IER (Type or Print
<br />Jana ;A. Matoreme;;,MD, 800 N Alpha Street, Grand Island;:;Nebra
<br />E) YEa
<br />2eb. WAS CONSENT
<br />Not Aesil It See *NO
<br />lib, DATE FiLED BY R
<br />July 17,20t9
<br />1. DSOEDENT'S=NAME (FIrat, ' Mlddls, 'Les
<br />Violet Berni9e Winfrey
<br />ITY:4WD ;!(TAl' f:oftTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
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