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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, rrCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOROON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS7W"9gTX*1 wICH IS,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DATE OF ISSUANCE
<br />7/1/2004
<br />200502923
<br />- �9(yLEY,4. CO9PER
<br />A SI5TAAI A ftGISYRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SITWCES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT' OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS /j 07086
<br />CERTIFICATE OF DEATH �}
<br />1. DECEDENT NT, FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year/
<br />Ferdinand Fredrick Wicht
<br />Male
<br />June 20, 2004
<br />4. CITY AND STATE OF BIRTH (ll not in U.S.A.. name country)
<br />5a. AGE • Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 .DAY
<br />6. DATE OF BIRTH fMonM. Day. Year)
<br />Duff, Nebraska
<br />(Yrs.) 87 5b.
<br />MOS. DAYS
<br />5c. HOURS Mws.
<br />June 19, 1917
<br />oil
<br />C
<br />$a. PLACE OF DEATH
<br />in
<br />❑
<br />507 - 48 -5525
<br />HOSPITAL: Inpatient OTHER: Nursing Home
<br />-- --
<br />❑ ER Outpatlem ❑ Residence
<br />-
<br />�.�
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other (5•pecGh4
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />n
<br />X
<br />Grand Island, 68801
<br />Yee R] No ❑
<br />•1.,.1..
<br />ga. RESIDENCE -STATE
<br />-
<br />9C. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /including Zip Code)
<br />ly
<br />a
<br />Hall
<br />Wood River
<br />1401 East Street 68883
<br />Yes © No ❑
<br />10. RACE • (e.g., White, Black American Indian.
<br />11. ANCESTRY (e,g.. Italian. Mexican, German, etc)
<br />12. ❑ MARRIED WIDOWED
<br />0
<br />13, NAME OF SPOUSE (If wita. give maiden name)
<br />eke.) (Specify) White
<br />(Specify) G .n
<br />NEVER DIVORCED
<br />Berniece Hazel Hershfield
<br />14a. USUAL OCCUPATION /Give kindof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary or Secondary (0.12) College 11 -4 or 5 +1
<br />of w lung fife, even if refired!
<br />farmer /rancher
<br />agriculture
<br />16, FATHER - NAME FIRST MIDDLE LAST
<br />j
<br />L
<br />yC
<br />Z
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no, or unk.) (If yes. give war and dales Of services)
<br />7
<br />ca`_
<br />NO
<br />*I
<br />CZ)
<br />20. EM M R - 1ATURE & L SE
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 210.
<br />CEMETERY OR CREMATORY NAME
<br />c
<br />Burial ❑ Removal
<br />Jun 24, 2004
<br />Cedarview Cemetery
<br />22a. FU97L ROME - NAMIF
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />Cil
<br />Doniphan, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Is). (b), AND (c)) I Interval between onset and death
<br />PART � .•�� 1
<br />t C `kc(:3
<br />-VV,Zl \ Mk
<br />I Is) kC
<br />DUE TO, 0`AS A CONSECUENCE OF Interval oeMreen onset and death
<br />N" Q_Q � r._. '1 a �4 MC \�e. r-.Y` \ j
<br />,i
<br />DUE TO, OR AS A CONSEOUENCE OF Imer ei between onset and ceap"
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - d %inns contributing to the death but not re ed PART
<br />CD
<br />PQ
<br />(ar a
<br />PAR f__ �` Cj \` N'Lk�_ PREGNANCY
<br />Y\
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />• A
<br />-eo0 ( (Ages
<br />Yes No
<br />Vas No
<br />f-
<br />26b. DAT OF INJURY (Mo.. Day. Yr)
<br />W
<br />26d. DESCRIBE HOW IN,:JRY OCCURRED
<br />Accident Undetermined
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<br />Suicide Pending
<br />a
<br />26f, PLAC� RF.INJURV • At ho � ,farm. street, factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />c
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<br />n Ice m dm g, ale, (Spec
<br />270. DATE OF DEATH (Mo.. Day, Yr)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />281b. TIME OF DEATH
<br />June 20, 2004
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<br />27b, DATE SIGNS /Mb. Day. Yr)
<br />27C. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Hour)
<br />3 O
<br />M
<br />s
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<br />27d To the best of knowledge. m occurred at the time, date ang, lace and due to the
<br />280. On the basis of examination and,or investigation, in my opinion death occurred at
<br />- .
<br />causelsl stated. •�
<br />/LL
<br />i n
<br />the time. date and place and due to the cause(s) stated.
<br />Co
<br />V)
<br />w z
<br />29, DID TOBACCO USE CONTRISUY TH? 30.a
<br />(�
<br />WAS CONSENT GRANTED?
<br />❑ YES 14 NO ❑ UNKNOWN
<br />❑ YES X NO
<br />❑ YES �. NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Typo or Print)
<br />S.L. Husen, MD 2116 West Faidley Ave. #400 Grand Island, Nebraska. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr,)
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<br />�1A Irt
<br />W H
<br />M� N
<br />OW! W
<br />Fa11
<br />w
<br />•
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, rrCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOROON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS7W"9gTX*1 wICH IS,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DATE OF ISSUANCE
<br />7/1/2004
<br />200502923
<br />- �9(yLEY,4. CO9PER
<br />A SI5TAAI A ftGISYRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SITWCES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT' OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS /j 07086
<br />CERTIFICATE OF DEATH �}
<br />1. DECEDENT NT, FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year/
<br />Ferdinand Fredrick Wicht
<br />Male
<br />June 20, 2004
<br />4. CITY AND STATE OF BIRTH (ll not in U.S.A.. name country)
<br />5a. AGE • Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 .DAY
<br />6. DATE OF BIRTH fMonM. Day. Year)
<br />Duff, Nebraska
<br />(Yrs.) 87 5b.
<br />MOS. DAYS
<br />5c. HOURS Mws.
<br />June 19, 1917
<br />7, SOCIAL SECURTIY NUMBER
<br />$a. PLACE OF DEATH
<br />❑
<br />507 - 48 -5525
<br />HOSPITAL: Inpatient OTHER: Nursing Home
<br />-- --
<br />❑ ER Outpatlem ❑ Residence
<br />8b. FACILITY - Name (If not institution, give sheet and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other (5•pecGh4
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island, 68801
<br />Yee R] No ❑
<br />Hall
<br />ga. RESIDENCE -STATE
<br />9b. COUNTY
<br />9C. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /including Zip Code)
<br />Be . INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Wood River
<br />1401 East Street 68883
<br />Yes © No ❑
<br />10. RACE • (e.g., White, Black American Indian.
<br />11. ANCESTRY (e,g.. Italian. Mexican, German, etc)
<br />12. ❑ MARRIED WIDOWED
<br />0
<br />13, NAME OF SPOUSE (If wita. give maiden name)
<br />eke.) (Specify) White
<br />(Specify) G .n
<br />NEVER DIVORCED
<br />Berniece Hazel Hershfield
<br />14a. USUAL OCCUPATION /Give kindof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementary or Secondary (0.12) College 11 -4 or 5 +1
<br />of w lung fife, even if refired!
<br />farmer /rancher
<br />agriculture
<br />g
<br />16, FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />�17.MOTHER
<br />Ferdinand Wicht
<br />Minnie Seier
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no, or unk.) (If yes. give war and dales Of services)
<br />Pat Stange
<br />NO
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIP)
<br />503 N. Blue River Avenue Juniata, NE 68955
<br />20. EM M R - 1ATURE & L SE
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 210.
<br />CEMETERY OR CREMATORY NAME
<br />c
<br />Burial ❑ Removal
<br />Jun 24, 2004
<br />Cedarview Cemetery
<br />22a. FU97L ROME - NAMIF
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ demotion ❑ Donation
<br />Doniphan, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Is). (b), AND (c)) I Interval between onset and death
<br />PART � .•�� 1
<br />t C `kc(:3
<br />-VV,Zl \ Mk
<br />I Is) kC
<br />DUE TO, 0`AS A CONSECUENCE OF Interval oeMreen onset and death
<br />N" Q_Q � r._. '1 a �4 MC \�e. r-.Y` \ j
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF Imer ei between onset and ceap"
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - d %inns contributing to the death but not re ed PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PAR f__ �` Cj \` N'Lk�_ PREGNANCY
<br />Y\
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />• A
<br />-eo0 ( (Ages
<br />10.54) Ves NO
<br />Yes No
<br />Vas No
<br />26a.
<br />26b. DAT OF INJURY (Mo.. Day. Yr)
<br />28c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN,:JRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f, PLAC� RF.INJURV • At ho � ,farm. street, factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />n Ice m dm g, ale, (Spec
<br />270. DATE OF DEATH (Mo.. Day, Yr)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />281b. TIME OF DEATH
<br />June 20, 2004
<br />w
<br />M
<br />27b, DATE SIGNS /Mb. Day. Yr)
<br />27C. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Hour)
<br />3 O
<br />M
<br />s
<br />M
<br />27d To the best of knowledge. m occurred at the time, date ang, lace and due to the
<br />280. On the basis of examination and,or investigation, in my opinion death occurred at
<br />- .
<br />causelsl stated. •�
<br />/LL
<br />i n
<br />the time. date and place and due to the cause(s) stated.
<br />(Signature and Title
<br />Si nature and Title 0
<br />29, DID TOBACCO USE CONTRISUY TH? 30.a
<br />HAS ORGAN OB.TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES 14 NO ❑ UNKNOWN
<br />❑ YES X NO
<br />❑ YES �. NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Typo or Print)
<br />S.L. Husen, MD 2116 West Faidley Ave. #400 Grand Island, Nebraska. 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr,)
<br />JUN 3 � 200
<br />If W
<br />
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