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<br />........,1IiI
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, "CERnFIES THE BELOW TO BE A TRUE COpy OF THE ORlG~~~PORD ON FILE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL ~2t;TION, WHICH IS
<br />
<br />
<br />:TELE;::=ORYF;~T;;;~; 16 1!4~'r!~R
<br />
<br />7/12/2004 ~~. cA..~. --tI1:.,E.... .'~"- 'GISTRAR
<br />LINCOLN, NEBRASKA !ili:A~~-" ,. . !JSYSTEM
<br />.. ~ " '.. . '..'0.; .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEAL1HAND HtJMA1.lS~FINIJil~ MID SUPPORT
<br />CERTI~~;;~~~~~A~:;~.':"'" o~: .'= 0 4 07 446
<br />
<br />Frederick
<br />
<br />William
<br />
<br />Male
<br />
<br />
<br />{Month, Day. Year)
<br />
<br />,. DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX .
<br />
<br />Hotz
<br />
<br />2004
<br />
<br />Omaha, Nebraska
<br />7. SOCIAL SECURTIY NuMBER
<br />
<br />5.. AGE. L... Birthday UNOE;R 1 YEAR UNOER 1 OA y
<br />IY...I 5b. MOS. DAYS 5e, HOURS' MINS.
<br />79
<br />
<br />December 4,
<br />
<br />1924
<br />
<br />4. CITYANDSTATEO~8IFlrH tlfnotinU,SA.,f1amecountry)
<br />
<br />505-20-7470
<br />
<br />8.. PLAC~ OF DI;A TH
<br />~~PI~~
<br />
<br />o
<br />o
<br />o
<br />
<br />ER Outpatient
<br />
<br />Inpatient
<br />
<br />OTHER:
<br />
<br />[XI NurSing Home
<br />
<br />o Fh:!sldence
<br />
<br />o Other (Speedv!
<br />
<br />Bb. FACILITY - Name
<br />
<br />(If nol institution. give str(flel ana number)
<br />
<br />Grand Island Nebraska Veterans Horne
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />DOA
<br />
<br />8d, INSIDE; CITY LIMITS 8e COUNTY OF DEATH
<br />
<br />11. ANCESTRY ((I.g.. Italian. MeXIcan, German, aIel
<br />ISpeelfyl American
<br />
<br />
<br />Hall
<br />
<br />Grand Island
<br />9.. RESIDENC~. ST MS
<br />
<br />Nebraska
<br />
<br />
<br />9d. STREST AND NUMSE;R (InClUding Zip Code)
<br />
<br />8e INS10E CITY UMI1S
<br />
<br />10. RACE - (e.g., White. ,Black. American Indian.
<br />etc.llSpecity) Wh i t e
<br />
<br />Oklahoma 68801 Yos [] No 0
<br />1:3. NAME OF SPOUSE (Jfwlle. give maiden niHtliiJ)
<br />
<br />14a. USUAL OCCUPATION (GIV~ kind of work dOne during mosl
<br />of workmg life, even if retired)
<br />Principal
<br />
<br />16. FATHER. NAME FIRST MIDDLg
<br />
<br />Elementary Schools
<br />LAST 17 MOTHER
<br />
<br />Wilma O.Bayer
<br />
<br />15. EDUCAilON (Specify only hlghast grade completed)
<br />Elemenlary or Secondary IO-12l S:oi1~e (1-4 or S'I
<br />t> rears
<br />MIDDLE MAIDEN SURNAMS
<br />
<br />Herbert Wesley Hotz Margaret
<br />
<br />'". WAS DECEASSD EVER IN U.S. ARMED FORCES?
<br />(Yes. no. or unk.) (II yes. give war and dates of servicesl
<br />Yes II 5-26-1944/8,15-1945 Wilma Hotz
<br />
<br />19b. INFORMANT MAILING ADDRESS ISTR~ET OR R,FO. NO.. CITY OR TOWN, STAT~. ZIPI
<br />
<br />Fern
<br />
<br />Ward
<br />
<br />
<br />
<br />Oklahoma. Grand Island, Nebraska 68801
<br />MBALMER. SIGNATURS 8 LICENSE NO. 21a.METHOD OF DISPOSITION 21b. DATE
<br />
<br />R- ~ti'l ~ 0 Sur;.1 0 Remov.1
<br />
<br />21e. CEMETERY OR CREMATORY NAME
<br />
<br />Jul 10, 2004 NE State Anatomical Board
<br />21d. CEMSTERY OR CRSMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Livingston-Sondermann F .H. Ocremallon ~Donal'on
<br />22b, FUNERAL HOME ADDR~SS [STREET OR R,F,D, NO.. CITY OR TOWN, STATE. ZIPI
<br />
<br />Omaha, Nebraska
<br />
<br />601 N. Webb Road,
<br />23. IMM~DIATE CAUSE
<br />P~AT Pneumonia
<br />(al
<br />DUE TO. OR AS A CONSgOUENCE OF
<br />
<br />Ib) Dysphagia
<br />
<br />ouE TO. OR AS A CONSEOUSNCS OF'
<br />
<br />Grand Island. Nebraska 68803-4050
<br />[ENTER ONLY ONE CAUSE PSR LINE FOR 1".lbl. AND (ell
<br />
<br />Interval between onset arld death
<br />
<br />26'.
<br />0 AcCident 0 Undetermined
<br />0 Suicide 0 pending
<br />0 Homicide Invesllgatlon
<br />
<br />26b. DATE OF INJURY {Mo" Day. Y'J 26c, HOUR OF INJURY
<br />
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />25. WAS CASE REFSRRED TO M~DICAL
<br />EXAMINER OR CQRONE;H?
<br />
<br />Interval between on!';et aM death
<br />
<br />14 Days
<br />
<br />27 Days
<br />
<br />Interval between Onset and dealh
<br />
<br />lei Parkinson's Disease
<br />PARi OTHER SIGNI~ICANT CONDlll0NS - Conditions contributing to the death but not related
<br />II Alzheimers DEmentia
<br />
<br />9 Years
<br />
<br />26.. INJURY AT WORK
<br />Yes 0 No 0
<br />27a. DATE OF DEATH (Mo.. Day, y;,)
<br />
<br />26g. LOCATION
<br />
<br />STREST OR R.FD, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />28a. DATE SIGNED IMo" Day. Yr.)
<br />
<br />28b TIME OF DEATH
<br />
<br />~~
<br />h~
<br />9-00 .~
<br />,,~ z
<br />o ~co
<br />u~
<br />.Il c
<br />I'~
<br />
<br />July 6, 2004
<br />27b. DATE SIGNSD IMo.. Day, Yr.}
<br />July 8,
<br />
<br />28e. PRONOUNCED DEAD IMo, Oay. Yr.)
<br />
<br />2ed. PRONQUNCED DEAD (HOui'!
<br />
<br />
<br />6:17 P.
<br />
<br />~H
<br />!l~:S
<br />_I1=;-
<br />~~<< ~
<br />8~1=~
<br />.Il!ii8
<br />~~u
<br />co -
<br />u 0
<br />
<br />M
<br />
<br />M
<br />
<br />M
<br />
<br />288. On the basis of examination aM'or investigation. in my opinion dea.th occurred at
<br />the time. date and place .and due to ~he cause/51 stated.
<br />
<br />NO
<br />
<br />30.b WAS CONS~NT GRANTED?
<br />DYES [iJ NO
<br />
<br />29.
<br />
<br />31. NAME AND ADORESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />
<br />steve Higgins, H.D., Grand I land Veterans Home, Grand
<br />32.. REGISTRAR
<br />
<br />
<br />Island, tlli 68803
<br />32b DATE FILSD B]Ur= (~' ~0fi4
<br />
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