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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT -OF 09ALTH, <br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECaRD:ON,FILE WITH THE TATE <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH &IM_ -0 LEdAL DEPOSITORY FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />SEP 2 0 1995 2 0 0 5 0 4'71 g -_STAN EYS. COOPER <br />AgS %STANT ST TE REGbSTRAR <br />LINCOLN, NEBRASKA NEBRASK"NPARTMFN-T OF- HEALTH <br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />3 DATc OF DEATH (Month Dav Year) <br />Walter F. Holtz <br />Male <br />August 25, 1995 <br />4 CITY AND STATE OF BIRTH IHnolP US.A.. namecourloy 5a AGE- Last Bidhday UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DA *E OF BIRTH IMOnfh. pdv Year) <br />�. WOURs MINS <br />Shelton, Nebraska rvrSl 84 6b Mos DAYS <br />May 21, 1911 <br />- 7 SOCIAL SECURTIY NUMBER <br />Sa PLACE OF DEATH <br />508 - 46-6474 <br />HOSPITAL ❑ Inpat1er11 OTHER Nursing Nome <br />❑ FR Oulpatlenl ❑ Resin¢nr.e <br />X�66 FACILITY Name lH ndl in5mylgn. give 5f /eCl and dumber) <br />"'P-r�PIace- Nursing Center <br />❑ DOA [j <br />288 DATE SIGNED /Md Dfly. Y,) <br />Sher (Sa ,b <br />Be CITY TOWN OR LOCATION OF DEATH <br />INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />�Ikl <br />Yes ® <br />❑ <br />Hall <br />29 DIE) TOBACCO USE CONTRIBUT M ATH'f <br />Na <br />30.b WAS CONSENT GRANTED" <br />9a. RESIDENCE -STATE 9b COUNTY 9c C1TV. TOWN OR LOCATON gd STREET AND NUMBER r+, -udmg Zrp Co,,, 9E INSIDE CITY LIMIT$ <br />Nebraska Hall Grand Island 216 W. 17th Street, 68801 Yes ❑X No ❑ <br />10 RACE - leg. , white Black American Indian 11. ANCESTRY leg Italian. Mexican. German, etcl 12 ®MARRIED ❑ WIDOWED 13 NAME OF SPOUSE dt -de Pita marched name) <br />etc.) ISoen ISW'tyl <br />White American NEVER DIVORCED Agnes Gruhn <br />MARRI <br />14a USUAL OCCUPATION IGrve Nndo/ work done during mo51 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION Spec Ay Unly )lignest gratle completed) <br />Of working fife, even rl retired) _� <br />Elemenly Secondary 10 121 College n 4 01 7 • <br />- Farmer _ Agriculture <br />i16 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MICJLE MAIDEN SURNAME <br />Fred Holtz <br />Meta Meissner <br />- 18 WAS DECEASED <br />EVER IN US ARMED FORCES? <br />19a INFORMANT -NAME '""• <br />_ (Yes, no or unk.l <br />In yes give war arid oases of se -Cesl <br />No <br />Agnes Holtz <br />19b INFORMANT MAILING ADDRESS (STREET OR R.F D NO., CITY OR TOWN. STATE. ZIP) ,• <br />216 W. 17th Street Grand Island Nebraska 68801 <br />20 EMBALMER- 5IdN07URE B LICENSfq Np ' <br />21a. METHOD OF o16POSITION <br />21b. DATE 21c <br />CEki *ERYORCREMATOHY NAME <br />0,11A.14 it #1212 <br />0 Burial ❑ Removal <br />08/28/1995 <br />Westlawn Memorial Park Cemete <br />22a. FUNERAL HOME NAME <br />210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel- Butler -G des Funeral Home <br />❑ Cremalon ❑ Donal'or <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) •---- <br />1123 West Second Grand Island Nebraska 68801 -5899 <br />i r• PART r= �Av ENTER eH 0rvu ONE uNux vEH LINE FUH Ial. Oil. AND (C)I Interval between onset and deatn <br />1111 I <br />I <br />la! F� rafrac�rnry GC�1gsQSta.Sif' heart,iare. Approx- 2 weeks <br />D�JE A a J .,F VENC nc I heel- 00hveen ones:.( isueam -... <br />i <br />lb). Longstanding ASCVD. Years <br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and dealn <br />I.) Generalized arteriosclerosis. <br />T•�OTTHEER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART <br />PAR OBS . Generalized WD. �1 PREGNANCY <br />Cerebrovascular disease, status post C <br />III IF FEMALE. WAS TWERE A <br />IN THE PAST 3 MONTHS? <br />Ages 10 -54) Yes No <br />24 AUTO =, <br />Yes No <br />25. WAS CASE REFERRED TO MEDICAI <br />E %AMINER pR CORONER" <br />Yes No FYI <br />26a <br />26b DATE OF INJURY /Mo.. Day. Yr./ <br />Ac HOUR OF INJURY <br />26d. DESCRIBE. HOW INJURY OCCURRED <br />0 Accident ❑ Undetermined <br />M <br />Suicide ❑ Pending <br />❑ Homicide Investigation <br />26e. INJURY AT WORK <br />Yes[] No ❑ <br />261. Vice INJURY (S� e, farm, street, factory <br />o i <br />26g. LOCATION STREET ON „= D NO CITY OR TOWN STATE m <br />I <br />1 <br />I <br />27a DATE OF DEATH /MO DD7ary. /J) <br />v l.1 <br />a r <br />°_ '• <br />288 DATE SIGNED /Md Dfly. Y,) <br />2Bb 11ME OF DEATH <br />M <br />27b DATE SIGNED (Md Day Yrl <br />27c TIME OF DEATW <br />28c PRONOUNCED DEAD (Mo Da), . _ <br />_ <br />28d. PRONOUNCED DEAD (Hourr u <br />27d To the best of my edge death occurred a1 da place and due to the <br />causelsl staled. - <br />�ISi9nature and Tine Ili <br />— <br />28e. On the busts of examination and or r~.esegahpn, in my opinion death occurred al <br />the ome, date and place and due to the causels) slated. <br />S naNra arld Tine <br />29 DIE) TOBACCO USE CONTRIBUT M ATH'f <br />Spa HAS O SSUE DONATION BEEN CONSIDERED <br />30.b WAS CONSENT GRANTED" <br />❑ YES ❑ NO ® UNKNOWN <br />❑ YES ® NO <br />❑ YES ® NO <br />31 NAMEANDADORE OF ERTIFtER IPHY CA 0 NEfi PHY$ IANOR OLj0tMA pR yl IT Fin i <br />Dr. Steven usen, 21 g a, ley ve. ulte 4, ran island, Nebraska 68803 <br />w-.. <br />32a REGISTRAR <br />32b DATE FILED TRAR$1995/ <br />a4k <br />� <br />