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<br />..
<br />
<br />STATE OF NEBRASKA
<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 REGlJRHDN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7".t~;tfcrriiiifil~WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. i.lfjjl~'ff"~~~
<br />
<br />DATE OF ISSUANCE 'r~':"IJrAN~Y S. d&JAER
<br />
<br />AUG 1 72005 200605119 ASS/$TAilis'fA'FERE~I$TflAR
<br />LINCOLN, NEBRASKA H~~L'tH.~~~~,-~~~A~ ~~ES
<br />~- ..~,>..~..~,:.~, :',:: -~"~-
<br />-. . ..i"','."'.~ -.,..:.. ~'~
<br />STATE OF NEBRASKA -- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN~EiN!?.~jJPpp~;.tr5" 0 8 9 3 6
<br />CE~!IFICATE OF DEATH __.~_.. ....::-';
<br />
<br />,-, :
<br />
<br />'\
<br />
<br />"'-
<br />"-J
<br />
<br />
<br />1.0ECEDENT'S.NAME (First, Middle, Last,
<br />Will i a~_l? h':l:._~...De ge n
<br />
<br />Suflix)
<br />Sr.
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />ugust 9, 2005
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />August 11, 1927
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />
<br />5.. AGE.Lasl Birthday
<br />(Yrs.) 77
<br />
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-22-8830
<br />
<br />aa. PLACE OF DEATH
<br />
<br />t:I.Q.SEJIAl.:
<br />
<br />IX!lnpallent
<br />
<br />illl:IER; 0 Nursing Horna/LTC 0 Hospice Facility
<br />
<br />6b. FACILlTY.NAME (If not Institution, giva slreet and number)
<br />Francis Medical Center
<br />
<br />o ER/Oulpallent
<br />
<br />o Decedent's Horne
<br />
<br />OCO\
<br />
<br />o Other (Specify)
<br />
<br />60. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />
<br />Island
<br />
<br />68803
<br />._19b:oUNTY H a 11
<br />
<br />Island
<br />
<br />90 APT NO' ~I ZIP CODE -- ~- 9g INSIDE CITY LIMITS
<br />1 2 6880 1 ~ YES 0 NO
<br />------------ -----
<br />lab. NAME OF SPOUSE (Flrsl, Middle, L..I, Sulfix) II wile, give m.iden name.
<br />
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />9d. STREET AND NUMBER
<br />1314 W. Charles
<br />
<br />St.
<br />
<br />10.. MARITAL STATUS ATTIME OF DEATH iXMorrled 0 Never Married
<br />
<br />o Married, bul .oparated 0 Widowed 0 Divorced lJ Unknown
<br />
<br />Mary Ann Wondercheck
<br />
<br />11. FATHER'S.NAME (First,
<br />John
<br />
<br />Mlddla,
<br />H e.f!r y
<br />
<br />Last,
<br />
<br />Sutlix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Marie
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Stelk
<br />
<br />Degen
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dale. 01 service II ye.. 14a.INFORMANT.NAME
<br />
<br />(YeJ~ ~.u_nk.l~O) /50-6/23/54
<br />15. METHOD OF DISPOSITION
<br />Xl Burial 0 Donation
<br />
<br />o Ramoval
<br />
<br />lJ Othar (Specify)
<br />
<br />16a. ;M,.LMER.SIGNATU E
<br />,\)'lJU..-L . B"~~
<br />16d. CEMETERY, REMATORY OR OTHEMoCATION
<br />Grand Island City Cemetery
<br />
<br />
<br />g.e"I-'_--~-""
<br />l6b. LICENSE NO.
<br />1328
<br />...'._--
<br />CITY /TOWN
<br />
<br />Grand
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />o Cremation 0 Entombment
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />
<br />August 12,
<br />STATE
<br />
<br />Island,Nebraska
<br />
<br />2005
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Stroel, City or Town, Stata)
<br />Funeral Home,2929 S.
<br />
<br />
<br />
<br />PART I. Enter the ~hain qLe_'LB_nls:-diseases, Injuries, or compllcatlons--lhat directly caused lhe death, DO NOT enler terminal even Is such AS cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showIng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add addl1lonalllnes If necessary.
<br />
<br />IMMEDtA TE CAUSE (Final
<br />dlsea" Of condition resulting
<br />In death)
<br />
<br />Soquontl.tlyll.toondltlono,II . (b).. .MLT~ ~.~.~n C
<br />any,loadlngtothooou.onoted .. "DUE TO, OR AS A CONSEQUENCE oF': ,.." n_"
<br />on line 8.
<br />Enter tho UNDERLYING CAUSE
<br />(d'.oo.. or Inlury that Inltl.tad (0)
<br />thl:! sV8nls resultl"9 In dSl!!lth)
<br />lAS1"
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) t\~C \~
<br />
<br />onset to death
<br />
<br />
<br />t-,)
<br />
<br />,-.,
<br />
<br />tt.J\:c~
<br />
<br />\~
<br />
<br />
<br />~\
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />) EM. \ ~ ~..~_~..
<br />
<br />I onset to dealh
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />.1
<br />I
<br />I
<br />I
<br />
<br />~~..~.~~
<br />
<br />onsal to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.at to dealh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT "ONDITIONs-conditlons contributing 10 the death but not resulllng In lhe underlying cause glvan In PART I.
<br />
<br />
<br />f\t .J\'C \ C _~~ N.~_~__.__~~_~_LV~ ;;:-
<br />
<br />19. WAS MEDICAL EXAMrNER
<br />OR CORONER CONTACTED?
<br />
<br />o YES }it NO
<br />
<br />20. IF FEMALE:
<br />o Not pregnant within pa.t yeer
<br />o Pregnant alUms of death
<br />o Not pregnant, but pregnant wilhln 42 days of death
<br />o Not pregnanl, but pregnant 43 days 10 1 year belore death
<br />o Unknown if pmgnant within the past year
<br />
<br />21.. MANNER OF DEATH
<br />~atural 0 Homicide
<br />
<br />o AccldenlO Pending Inves11gallon
<br />
<br />21 b. IF TRANSPORTATrON INJURY
<br />o Driver/Operator
<br />
<br />o Passengar
<br />
<br />[J Pede.trlan
<br />
<br />o Other (Specify)
<br />
<br />210. WAS AN AUTOPSY PERFORMED?
<br />o YES ~O
<br />
<br />o Suicide 0 Could not be dotormlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.AI home, farm, street, faclory, office building. construcllon sUe, elc. (Specify)
<br />m
<br />
<br />22d. INJURY AT WORK7
<br />
<br />221. LOCATION OF INJURY" STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOwN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 9, 2005
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />w--.-Ci
<br />
<br />",~i:;
<br />.cUZ
<br />n~
<br />a,D.. 4:( ~
<br />~ ...~~
<br />uffiz
<br />1!z=>
<br />00
<br />~a:O
<br />81;
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />07:45 "A. m
<br />
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />~
<br />
<br />24e. On Ihe basIs of examination and/or investigation, In my opinIon death occurred at
<br />thalirne, date and place and duo to the cau.a(.) .1.led. (Signalure .nd Tille) '"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />.... .... _l:ly~~~"R.~'?".nI:lP~'?~~~~Y_._..9__\JN..KNOWN 0 YES "'G.N0
<br />27. NAME, TITLE AND ~DDRESS OF Ct;;RTIFIEA (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John J. Cannella, M.D. 729 N. Custer Ave.,Grand
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Appl!c.~~lo II 26a Is N,?._g..YES 0 NO
<br />
<br />2a.. REGISTRAR'S SIGNATURE
<br />
<br />~J.
<br />
<br />
<br />Island, NE
<br />
<br />68803
<br />
<br />2ab. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG 15 2005
<br />
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