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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 RECOBDoJ}NF-H.~.W~TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS sttCi{~Wfl!~l"-1$..
<br />
<br />::;;::~;:::::;TORY FOR VITAL RECORDS'_1:y:2~iJ~:,~':c~=:
<br />~A"_i;' OOPPE"'oC;
<br />A SSISTA.NicSTATE REGisTRA6.~! [?
<br />HEALTH 1t~iJi#,!M~N SERVICES': F
<br />
<br />OCT 2 4 2005
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200600498
<br />
<br />\/)
<br />1
<br />
<br />J
<br />
<br />
<br />Clarence Edwa.J::d Greenwa1t.~__
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Last Birthday
<br />
<br />eb k (Yrs.) 78
<br />St. Libory, N ras a
<br />
<br />5b. UNDER 1 YEAR
<br />MOS _1 DAYS
<br />
<br />
<br />8a. PLACE OF DEATH
<br />
<br />Ie
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />15,_-.20.05....
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />1. DECEDENT'S-NAME (First,
<br />
<br />LaSI,
<br />
<br />SuffiX)
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />July 17, 1927
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-9139
<br />
<br />R Outpallenl
<br />
<br />~ NurSing Home/LTC 0 Hospico Facility
<br />~~;/.",.'"''~''.'''''~;:'''f';;'-C:.:'''H:''.~'''''
<br />
<br />.I.":"".;:';,
<br />
<br />tIilli!'illlJ..:
<br />
<br />o Inpallenl QTIiIili:
<br />
<br />8b. FAGILITY-NAMF .!!I noUn,,;
<br />
<br />DecedetllJs Home
<br />
<br />Grand Island Veterans Hone
<br />
<br />0[\)\
<br />
<br />o Other (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island,-Nebraska 68803
<br />
<br />9.. RESIDENCE.STATE --- "-~b COUNTY -
<br />Nebraska Hall
<br />- --. ~.-
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />9d. STREET AND NUMBER
<br />1104 W Anna st.
<br />
<br />1 Oa. MARITAL STATUSAT'TlME- OF DEATH 1iI Married 0 Never Married
<br />
<br />Hall COlmty
<br />
<br />[~'=~ORTOWN Grand Island
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />!ill YES 0 NO
<br />
<br />lOb. NAME OF SPOUSE (First, Mlddla, Last, Suffix) II wife, give maiden nama.
<br />
<br />o Married, but saparaled 0 Widowed 0 Divorced U Unknown
<br />
<br />Dorthy Jane Stueven
<br />
<br />11. FATHER'S-NAME (First, Middle,
<br />John Henry Greenwalt
<br />
<br />Last,
<br />
<br />S-UffIX) -""112. MOTHER'S.NAME (First,
<br />_1_ Lucy (NMI) Grayek
<br />
<br />Middle,
<br />
<br />Maidsn Surname)
<br />
<br />o Cremallon U Enlombment
<br />
<br />
<br />Greenwalt
<br />
<br />FC)7~
<br />
<br />CITY !TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give datas of service it yes.
<br />No
<br />
<br />il Burial
<br />
<br />o Donallon
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />October 18, 2005
<br />
<br />STATE
<br />
<br />o Removal 0 Other (Specily)
<br />
<br />West1awn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />PART I. Enler Ihe d1aln.olllW1Ja--diseases, injuries, or compllcallons--thal directly caused the dealh. DO NOT anter terminal events such as cardiac arrest,
<br />re.plrelory erresl, or venlricular fibrillation wllhout ohowlng Ihe etiology. DO NOT ABBREVIATE. Enler only one CauSe on.aline, Add additional lines II necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />~:03de
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Cily or Town, Slete)
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />Onsello deatt!
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resultlng
<br />In death)
<br />
<br />(a) AC\Jt~_Cardio-Pu1monary FCiilure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />< 10 Hinute~L
<br />onoello deelh
<br />
<br />Sequentially list conditions, If
<br />any.l@sdingtothecausellsted
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that tnlUated
<br />!he events resulting in death)
<br />lASf
<br />
<br />(b) Dementia with Dysphagia and Cachexia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />I
<br />I
<br />
<br />..~_._~,-
<br />
<br />'- 5 Years
<br />
<br />onsello dealh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condilions contributing to Ihe dealh bUI nol resulting in the underlying cause given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES IXI NO
<br />
<br />Major Depressive Disorder, CDPD.
<br />
<br />20. IF FEMALE:
<br />o Nol pregnant within pas I year
<br />o Pregnant altime of death
<br />o Not pregnanl, bUI pregnant within 42 days of death
<br />[J Not pregnanl, but pregnant 43 days to 1 year belore death
<br />o Unknown if oregnanl wIthin lhe pas I year
<br />
<br />21a. MANNER OF DEATH
<br />~ Nalural 0 Homicide
<br />
<br />o AccldemO Pending Investigation
<br />
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o pessenger
<br />o Pedeslrian
<br />
<br />o YES
<br />
<br />XI NO
<br />
<br />o Suicide 0 Could nol be delermlned
<br />
<br />o Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />222. DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJU'RY
<br />m
<br />
<br />I --- m__,=-~ES _~~__
<br />
<br />22c. PLACE OF INJURY.AI home, farm, streel, faclory, ollice building, construction sile, etc. (Specify)
<br />
<br />22d. INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />. [J YES 0 NO
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />$WE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />October 15, 200?
<br />
<br />23b. OAT" SIGNED (Mo" Day, Yr.)
<br />October 17, 2005
<br />
<br />24a. OAT" SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TiME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />9: 10 Am
<br />
<br />:..:i ~
<br />.cuz
<br />U~
<br />c.a.. iIi; ~
<br />E">-Z
<br />8ffi~o
<br />llZ=>
<br />~~8
<br />o~
<br />uo
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or invBsligation, in my opInion dealh occurred at
<br />the time, date and place and duelo the causers) slaled. (Signature and Title) T
<br />
<br />25. DID TOBACCO USE CONTRIBUT" TO
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES t:4 NO 0 PROBABLY 0 UNKNOWN [J YES cXNO NOI Appllceble if 26a I~~.O YES XXNO
<br />.. . ii.NAME, TITLE AND ADDRESS OF CERTIFiER (pHYSICIAN, CORONER'S PHYSICiAN OiiCOUNTY ATTORNEY) (Type or Print)
<br />M.A. T kins M.D. Grand Island Veterans Hane, Grand Islam,}"lE 68803
<br />
<br />2Ba.REGISTRAR'SSIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />
<br />OCT 2 0 2005
<br />
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