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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDF/UMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REggflPP-l!_ FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS1)~JjSJ:?;ti(JN,c--';JQjJCH IS
<br />
<br />::::;:::::,TORY FOR VITAL RECORDS. ,*,E:~~
<br />OCT' 1 9 2005 A$SIStA'NTcSTAiEJiEf.>I$7J1Al1
<br />LINCOLN, NEBRASKA 2 0 0 5 1 0 9 0 0 HE~~"H~_~~ HUMAN SIJi'~5ES
<br />
<br />f
<br />
<br />
<br />--
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE-ANQ SGf'_~_FiT 0'5- 114 5 9
<br />CERTIFICATE OF DEATH - :c:.."" ,
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a, AGE-Laat Blrlhday 5b, UNDER 1 YEAR
<br />(Yrs_) MOS_ DAYS
<br />
<br />81
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3" DATE OF DEATH (Mo" Day, Yr,)
<br />October 1~, 200_5___
<br />6, DAT~ OF BIRTH (Mc_, Day, Yr.)
<br />
<br />DECEDENT'S.NAME (FlrSI,
<br />
<br />James
<br />
<br />Middle,
<br />A.
<br />
<br />Lasl, Suffix)
<br />Bixenmann
<br />
<br />2_SEX
<br />Male
<br />
<br />Grand Island, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />506-26-2306
<br />
<br />October 2, 1924
<br />
<br />6a, PLACE OF DEATH
<br />~:
<br />
<br />Xl Inpalianl
<br />
<br />Q!]jfB: 0 Nursing Hcme/LTC 0 H05pica Faclllly
<br />
<br />FACILITY-NAME (If nol Inslilullon, give slreel and number)
<br />
<br />U ER/Outpaticnt
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />OCO\
<br />
<br />U Olher (Specify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />Grand Island 68803
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g, INSIDE CITY LIMITS
<br />0( YES 0 NO
<br />
<br />""J
<br />
<br />9a, RI,SIDoNCE.STATE
<br />Nebraska
<br />9d, STREET AND NUMBOR
<br />
<br />9b COUNTY
<br />
<br />2412 N. Park Ave.
<br />-.-----..-
<br />10a, MARITAL STATUS ATTIME OF DEATH !XI Married 0 Never Married
<br />
<br />1 Ob, NAME OF SPOUSE (First, Middle, Lasl, Sufli') II wifa, giva maiden name,
<br />
<br />o Married. but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Irene K. Woznick
<br />--.-.', ", ---" ~---'-~-----------------"-"----'----------'~ '---"-,,. '--'.-:L-- -~ --------- ----.
<br />11. FATHER'S-NAME (Flrsl, Middle, Lasl, SUffl,) 12, MOTHER'S.NAME (Flrsl,
<br />John A. Bixenmann Armilta
<br />-.........- ,...-.." .--.------..,-
<br />13_ EVER IN U,S, ARMED FORCES? Giva dales of sarvice if yas_ 14a_INFORMANT.NAME
<br />
<br />Middle, Maiden Surname)
<br />
<br />Carl
<br />
<br />(Yes, no, or unk,)
<br />
<br />No
<br />
<br />
<br />Irene K. Bixenmann
<br />16b, LICENSE NO,
<br />I / 43,.
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />o Cramalion 0 Entombment
<br />
<br />16d, CEMEToRY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY / TOWN
<br />
<br />16c_ DATE (Mo_, Day, Yr.)
<br />
<br />Oct. 15, 2005
<br />
<br />STATE
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />(jiJurial
<br />
<br />o Donation
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island, NE
<br />
<br />.... ".--''''," "... - ....-
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slraat, City or Town, Slala)
<br />
<br />Livingston-Sondermann Funeral Horne, 601
<br />
<br />resplralory arresl, or venlrlcular fibrillation without showing the etiology, DO NOT ABBREVIATE, Enler only ona cause on etlne, Add addltlonellln.s It necessery,
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..."... or condllion resulting
<br />In dealh)
<br />
<br />.-r- IMMEDIATE CAUSE:
<br />
<br />(a) __ G4rJl'-'l..( /1rl'yjf"fY\.//A
<br />DUET-a, OR AS A CONSEQUENCE of:
<br />
<br />S.quenllally lI.t condlllon., If (b) /}.-r, '", tt-,;, '{",,,,,t-
<br />any, leadln9 tolh. causeltsted --tillE'To OR AS A C6NSEOUENCE OF-
<br />MII~!. ' .
<br />Ent.rth. UNDERLYING CAUSE
<br />(dl..... or Injury that Inltlat.d (c)
<br />lheevenlsre.ultin9Indeath) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />i",{-;.d(':"'"
<br />
<br />onsallo death
<br />1--\--
<br />I IVt , it ..f~
<br />I
<br />I onsello deelh
<br />I
<br />
<br />: OC<YJ
<br />
<br />I onsello dealh
<br />
<br />onset to dealh
<br />
<br />(d)
<br />
<br />20, IF FEMALE:
<br />
<br />21 a;~NER OF DEATH
<br />K rv .alural 0 Homlclda
<br />
<br />U AccldenlO Pending Inveellgellon
<br />
<br />, 9_ WAS MEDICAL EXAMINER
<br />X OR CORONER CONTACTED?
<br />_[]_:~S__!,~_~____
<br />
<br />21b_IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o DrlvarlOparator A-"'
<br />
<br />o Pessenger
<br />
<br />o YES
<br />
<br />fiNO
<br />
<br />PART II, OTHER SIGNIFICANT CONDITIONS,Conditlons conlrlbutlng 10 tho deelh bUI not rasultlng In Ihe underlying causa glvan In PART I.
<br />
<br />!?j'Y'\ I
<br />
<br />cHf-
<br />I
<br />
<br />L-u~
<br />
<br />CA
<br />
<br />o Not pregnant wilhin past year
<br />
<br />o pragnant al lima ot daalh
<br />o NOI pregnant, bUI pregnanl within 42 days of dealh
<br />
<br />o Pedestrian
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />o Suicide 0 Could nol be delermined
<br />o Nol pregnant, bul pregnanl43 days 10 1 yoar before dealh U Olhar (Specify) COMPL~TE CAUSE OF DEATH?
<br />
<br />o Unknown II pragnant wilhin Iha pas I yaar 0 YES 0 NO
<br />
<br />_:~~-DAT~~F~NJ_~,~:-iM~~.~y, Yr~~.. '}.22b' TIME~O-FiNJLJR~-r~~-PLACEQF INJURy.At homa,_~rm. ~lrael.;~~lory, ~c~b~d~ng, ~_~~.tr~,~o~::ile, eto. (Specify) __~__
<br />
<br />
<br />22d, INJURY AT WORK? 22a_ DESCRIBE HOW INJURY OCCURRED
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP COpE
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />October 11, 2005
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />-t' It;, II ~/~r
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23c_ TIME OF DEATH
<br />4:11 pm
<br />
<br />z,.
<br />:s-~~
<br />'t:Iiii~
<br />n~
<br />c.lL c.( ~
<br />E _"',. z
<br />8ffi!z:0
<br />,8z=>
<br />00
<br />~a:O
<br />81;
<br />
<br />m
<br />
<br />24c_ PRONOUNCED DEAD (Mo" Day, Yr_) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d_ To Iha basi of my knowledge, daalh occurrad 211he time, dala and place
<br />..>--- and due 10 Ihe cause(s) slated, (Slgnalure and Title) "
<br />
<br />,dfrth--''k, r. hip
<br />
<br />24e. On the basis of examInation and/or InvestlgaUon, In my opinion death occurred at
<br />Ihelime, dala and place and due 10 the cause(s) sleled, (Signature and Tille) "
<br />
<br />25, DID TOBACCO USE CONTRIBUT'tlG-TH",OEATH? 26a_ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />Y 0 YES CYNO 0 PROBABLY 0 UNKNOWN --- IJ YES NO
<br />2? ~E, TiTLE'A'NDADDRE~S OF.cERTIFIER (PHYSICIAN" CORONER'S PHYSICIAN OR COUN Y ATTORNEY) (Tvpe or PrlnlL
<br />~.Jc{r;:::. (t K ,'" 7:)" /t/ C/.<jk.;' 0:;. Afc &1101
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />26b_ WAS CONSENT GRANTED?
<br />k"'
<br />Nol Applicable if 26a is NO 0 YES
<br />
<br />NO
<br />
<br />
<br />28b, DATo FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />OCT 1 7 2005
<br />
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