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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDor"Lftf!;g WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/~I!~1WNi-"Wf11c!-lIS
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. . .,:.~? ~-~~wTe;;Pi=!t
<br />~rAM.EY,l;. i:ociPtFi~
<br />OCT 242005 200512 619 AS5LST~NT'sTATE'#Et;ismAFij
<br />. LINCOLN, NEBRASKA HEALTH ANQ H!JMANSERileE~/
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<br />STATE OF NEBRASKA - DEPAR~~~~tFJ~~i~~Q.~_UQ~~;.~VICES FINANCEANOSUPPClR:OS-----115-90__
<br />
<br />1. DECEDENT'S-NAME (Flrsl, Middle, Lasl, Sulflx) 2. SEX 3. DATE OF DEATH (Mo.. Day, Yr.)
<br />ClarenCEL__.~Qwcu;:d._GJ:::.eE:lPWal t
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-La" Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) 78 MOS. DAYS
<br />St. Libory, Nebraska
<br />
<br />~
<br />
<br />
<br />OCT 2 0 2005
<br />
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />July 17, 1927
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-9139
<br />
<br />8a. PLACE OF DEATH
<br />I:l.QS.fJIAL: 0 Inpallenl
<br />
<br />QlliE8; ~ Nursing Homa/LTC 0 Hospice Coclllly
<br />
<br />8b. FACILITY-NAME (If not institution. givo strect.~nd nu~ber)
<br />
<br />o ER/Outpallanl
<br />
<br />o Decedenl's Home
<br />
<br />Grand Island Veterans Hane
<br />
<br />o [X)I, 0 Other (Specify)
<br />
<br />.____=rCO~;:;~D~~~~;._.
<br />
<br />9c. CITY OR TOWN
<br />
<br />Be. CITY OR TOWN OF DEATH (Includs Zip Code)
<br />Grand Island,' Nebraska 68803
<br />
<br />98. RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />liII YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />1104 W Anna St.
<br />
<br />9UIP CODE
<br />68801
<br />
<br />10a. MARITAL STATUS AT TIME OF DEATH 1iI Married 0 Never Married lOb. NAME OF SPOUSE (First, Middl., Last, Sulfix) If wit., give maid.n nam..
<br />
<br />o Married, but seporated IJ Widowed IJ Divorced U Unknown Dorthy Jane S tueven
<br />
<br />11. FATHER'S.NAME (First, Middle,
<br />John Henry Greenwalt
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (Firsl, Middle,
<br />Lucy (NMI) Grayek
<br />
<br />Maiden Surname)
<br />
<br />'13. EVER IN U.S. ARMED FORCES? Givo dales 01 .orvlcolf yes. 14a.INFORMANT.NAME
<br />No Dorthy Jane Greenwalt
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. METHOD OF DISPOSITION
<br />il Burial 0 Donollon
<br />o Cremation 0 Entombmenl
<br />
<br />
<br />16c. DATE (Mo.. Dey, Yr. )
<br />October 18, 2005
<br />
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />o Removal IJ Olher (Spoclly)
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slr..I, Cily or Town, Slat.)
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />
<br />
<br />PART I. Enler Ihe chain 01 evonts--disaa.e" inJurlas, or compllcsllons-.lhal diraclly caused Iha dealh. DO NOT enler lermlnalevanls such a, cardiac arre't,
<br />respiralory arre5l, or venlrlcular tlbrlllallon wilhoUI.howlng tha ellology. DO NOT ABBREVIATE. Enler only One cause on a line. Add addltlonalllnssll necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) Acute._Car~ltQ:)?glm9DgLXCl.i-lur~___.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />I
<br />
<br />.'".~__< 10..l1i}:1.utE2e
<br />I ons.llo death
<br />I
<br />I t.. 5 Years
<br />
<br />IMMEOIATE CAUSE (Final
<br />disease or condition resulting
<br />in desth)
<br />
<br />Sequantlallyllstcondlllons,1I (b) Dementia with Dysphagia and Cachexia
<br />
<br />sny, 'oadlng 10 the causellsled D'UE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enlarthe UNDERLYING CAUSE
<br />(dl....e or Injury Ihallnlllal.d (c)
<br />Iheevenlsresulllng In deslh) DUE TO, OR AS A CONSEQUENCE OF;
<br />lAST
<br />
<br />on'ello daalh
<br />
<br />o",el to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS. Conditions contributing 10 tho de.lh but nol resulting in Ihe undorlying cau.. giv.n in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />Major Depressive Disorder, COPD.
<br />
<br />DYES
<br />
<br />~ NO
<br />
<br />20. IF FEMALE:
<br />o Not pregnant within past year
<br />o Pregnant at time of death
<br />o Nol pregnant, but pregnant within 42 days 01 death
<br />o Not pr.gnont, bul pregnant 43 days to 1 y.ar betore death
<br />o Unknown if p!egnanl wlthln.\ho pasl year
<br />
<br />21.. MANNER OF DEATH
<br />~ Nstural 0 Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drlver/Oparalor
<br />
<br />o paesenger
<br />
<br />o Pedestrian
<br />
<br />o Othar (Spaclly)
<br />
<br />2tc. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES Xl NO
<br />
<br />U AccldentO Pending In\lBstigation
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJU'RY 22c. PLACE OF INJURY.AI home, farm, streel, faclory, offic. building, con.lruclion sil., .Ic. (Specify)
<br />
<br />m
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />liP CODE
<br />
<br />23a. DATE OF DEAfH (Mo.. D.y, Yr.)
<br />
<br />_QS:~Q~J.2-,- 2005
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 17, 2005
<br />
<br />24.. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>~i:i
<br />.ctO:Z:
<br />11<ila:
<br />~~~
<br />c.a.. C ~
<br />H~25
<br />"lJJZ
<br />11"1: ::l
<br />00
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />9: 10 Am
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On Iha basis of ax ami nail on snd/or Invesllgation, in my opinion daalh occurred al
<br />Ihallme, dala and place and due 10 Ihe cau'e(s) "aled. (Slgnalure and Tille) T
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES M NO q PROBABLY 0 UNKNOWN 0 YES iXNO Nol Applicable If 26a Is NO 0 YES XX.NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORON~R'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />M.A. T kins M.D., Grand Island Veterans Hane, Grand Island, NE 68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
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