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<br />"
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SIrSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD-ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAmir.TC$ Sl!c;rNji;ff{HICH IS
<br />
<br />:::;:::~~~::~TORY FOR VITAL RECORDS.. ~_...'.<.~-. ":'.~A~. -~7~~;Y.~2.-,_~.-~~~
<br />MAR 03 200b 200605329 [.:;~~=:
<br />LINCOLN, NEBRASKA Hi;.4LTtt. AND HUMAt("cSiR~CES
<br />
<br />- -
<br />
<br />1
<br />
<br />
<br />S... T. AT. E.. .0.. .F NEBRAsKA - D.EPA. RTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND$1/PPORT C I). .212 4
<br />._umu_ _._______ CERTIFICATE OF DEATH D-O----L- . ___
<br />
<br />1. DECEDENT'S.NAME (First, Middle, Last. Suffix) 2, SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />Charles R. Witt Male H'_ February 20. 2006
<br />4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a_ AGE. Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo" Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />88
<br />
<br />August 20.
<br />
<br />1917
<br />
<br />Washington County, Colorado
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-03-2192
<br />
<br />6a. PLACE OF DEATH
<br />I::lQSPtIAL
<br />
<br />o Inpatlenl
<br />
<br />QIljfB: Xl Nursing Home/LTC 0 Hospice Facility
<br />
<br />6b. FACILITY-NAME (II not Institution, give street and number)
<br />
<br />o ER/Outpatlant
<br />
<br />U Decedent's Home
<br />
<br />Hamilton Manor
<br />
<br />DOC\'.
<br />
<br />D Other (Spacify)
<br />
<br />.,-,-,.,,_.__.~.~~~-,.,~~-",,"
<br />Be_ CITY OR TOWN OF DEATH (Includo Zip Code)
<br />
<br />'\
<br />
<br />Aurora
<br />9a. RESIDENCE-STATE
<br />
<br />68818
<br />
<br />ad. COUNTY OF DEATH
<br />Hamilton
<br />
<br />Nebraska
<br />9d_ STREET AND NUMBER
<br />
<br />9b.COUNTY
<br />Hamilton
<br />
<br />9c. CITY OR TOWN
<br />
<br />~11,t
<br />.'~'I~.."'"...".,..,.""
<br />!~ m
<br />~'.,f
<br />:~:;)\~
<br />
<br />1515 5th Street 68818
<br />
<br />10a. MARITAL STATUS AT TIME OF DEATH U Married W Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Sullix) If wifa, glva maldan name.
<br />
<br />
<br />91. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />rllI YES 0 NO
<br />
<br />o Marrlad, but aaperated iJrwldowed U Divorced LI Unknown
<br />
<br />11. FATHER'S.NAME (First,
<br />Charles
<br />
<br />Middl.,
<br />
<br />Last!
<br />
<br />Sulllx)
<br />
<br />12. MOTHER'S-NAME (First.
<br />Mabel
<br />
<br />Middle,
<br />B.
<br />
<br />Maid8n Surname)
<br />
<br />
<br />W.! u____ J~j.J_t
<br />
<br />Hunter
<br />
<br />(Yes, no, or unk.)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates 01 service if yes_ 14a_INFORMANT.NAME
<br />Colleen Kober
<br />
<br />No
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />15. METHOD OF DISPOSITION
<br />tleurlal 0 Donation
<br />
<br />o Cremation 0 Entombment
<br />
<br />16a, EMBALMER-SIGNATUR}j
<br />
<br />. W1:h1H~U(.~
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Parkview Cemetery
<br />
<br />16b. LICENSE NO.
<br />112.9
<br />
<br />Cl Removal 0 Olher (Spscily)
<br />
<br />CITY /TOWN
<br />Hastings
<br />
<br />16c_ DATE (MD., Day, Yr.)
<br />February 24,
<br />STATE
<br />Nebraska
<br />
<br />2006
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel. Clly orTown, Slate)
<br />Livingston-Butler-Volland Funeral Home
<br />
<br />**m"ji;
<br />
<br />~
<br />
<br />1225 North Elm Avenue
<br />Hastings, Nebraska
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or oondlllon re.ulllng
<br />In daalh)
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />(.) . _.J~h-~.t ~~~'~
<br />
<br />DUE TO. OR AS A CONSEQU"NCE OF:
<br />
<br />onsallO daalh
<br />
<br />^" ,.
<br />I~..
<br />
<br />
<br />Sequentially IIsl condlllona.lf (b)
<br />.ny.le.dlng 10 the c.usall.tad -DU€'TO~ORAS-A CONSEQUENCE OF:
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dlsaa.. or Injury th., Inlll.led (c)
<br />the .vent. re.ulllng In dealh)
<br />LAST
<br />
<br />I
<br />I
<br />I
<br />------'---
<br />I onsello death
<br />I
<br />I
<br />I
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsallo daath
<br />
<br />(d)
<br />
<br />.,-- -.".
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condillons contributing to Ihe daalh bUI nol r.sulllng In Ihe underlying causa givan in PART I.
<br />
<br />~I~
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES NO
<br />
<br />20. IF FEMALE:
<br />
<br />21 e. MANNER OF DEATH
<br />o Natural LJ Homicide
<br />
<br />21b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />1:1 Drlver/Oparalor
<br />
<br />
<br />U Not pregnant within past yaar
<br />o Pregnant al tlma of daalh 0 AccldentO Panding Invesligalion 0 Pa..ongor
<br />o Nnl pregnanl, but pregnant within 42 days of daath 0 Suiclda 0 Could nol be datermined 0 Pedeslrlan 21d. WI;RE AUTOPSY FINDINIJS AVAILABL" TO
<br />LI Not pragnant, but pregnant 43 days 10 1 year before dealh U Other (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown iI pragnant wllhin tho pas I yeer 0 YES 0 NO
<br />---
<br />::.a DAT" OF INJURY (Mo , ::,yr) __ 22b TIME OF INJUFI:' /22C' PLACE OF INJURY.At home, farm, slraat, 'aclory, office bUlld;;;;'-;nslrucllon slla, alc (Specify)
<br />
<br />
<br />
<br />22d INJURY AT WORK? -122a DESCRiBE HOW INJURY OCCURRED- n - n. --
<br />
<br />
<br />DYES 0 NO ~
<br />
<br />
<br />22'. LOCATION OF INJURY - STF:EET & NUMBER, APT. NO,
<br />
<br />DYES
<br />
<br />~O
<br />
<br />./
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />Ife1:g:\lllrv 20. ~iLQ9
<br />23b. DAT" SIGNED (Mo., Day, Yr.)
<br />2-2..?r 0(,
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />1/ !' ,0 f m
<br />
<br />,.~ i;j
<br />-'lUz
<br />"CenCI:
<br />n~
<br />Q. c.. CI: ::i
<br />liniS
<br />u"'z
<br />llz=>
<br />00
<br />~rr.u
<br />o ~
<br />U 0
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred at Ih. lime, date and placo
<br />and due 10 Ihe cause(slstaled. (Signature end Tllla) ,,-
<br />
<br />IYt ft 0 2-21-0[.
<br />
<br />.248. On the basis of examlnallon and/or Investlgatioll, in my opinion death occurred at
<br />thallme, date and place and dua 10 tha causers) stated. (Signature and Title) "
<br />
<br />25, DID TOBACCO USE CONTRiBUTETOTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Appllcablo if 26a is NO Cl YES ~()_
<br />
<br />
<br />_O__~ES ~O _r:J PROBABLY_---.9.UNKNOWN ~s 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Of Prlni)'-
<br />Mike Sullivan, M.D. 609 0 Street Aurora, Nebraska
<br />
<br />68818
<br />
<br />26a. REGISTRAR'S SIGNATUR"
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo_, Day, Yr.)
<br />
<br />}v~
<br />
<br />MAR 0 2 2006
<br />
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