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<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYS7E'1I( "CERTFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL REf,:ORD ONFILE'-WlTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS $ECTIffW,-ilntJijt=l.S
<br />THE LEGAL DEPOS/TDRYFPR VITAL RECORDS. ~_::- .:YC--"':jl"-i-- ~~:::::~ '\ "'-
<br />. ' - ~-:,
<br />DATE OF ISSUANCE 2 . -'-- - ~ , =
<br />NOV 1 6 2001 00605 718 ASS~.r~T:~~i~!~=i
<br />LINCOLN, NEBRASKA HEAL TH AND ,.;u,;,AN$f!B_VlCES$YSTEIE
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALrn AND HUMAN SERVlCF"S FIN;.rn~-E:AND S~RT
<br />CERTIV;;~S~~~~EA TH _: - -~" 01
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<br />12655
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<br />riE~'~rma -- HRST
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<br />
<br />h-'CITVANOSTATEOF"'H1H /lInol",USA "amocoun"y/
<br />
<br />Ong, Nebraska
<br />., SOCiAL SECURTIY NUMBER
<br />
<br />85
<br />
<br />
<br />MIr)()l,f LMn ? SEX
<br />
<br />3. OA TE-O~~ OEA TH rMonf/J. {Ji.lV rl::'drJ
<br />
<br />W. Witt Female'
<br />Si'l AGf Cas! 8irtMay UNDER t YEAR
<br />IV".I 5b. MOS DAYS
<br />
<br />November 01 2QQ1
<br />6. DATE OF BIRTH (Month, Day. YL~ilrj--' --.
<br />
<br />388-16-9668
<br />
<br />-..''(ii"nor insrituti(Jn. give slr~el and numoorl
<br />
<br />8a "'PiACE: OF DE:A TH
<br />~..lOSPIT_~ 0 Inpallenl
<br />o ER Oulpatient
<br />o DOA
<br />
<br />OTH~R 0 NI,Jrs,ng Home
<br />
<br />(i] Residence
<br />
<br />o Other ISfJt~ctfYI__ ,,_______
<br />
<br />Bb, F'A(~ILlTY - Namo
<br />
<br />405 Walnut
<br />
<br />Be Cll:Y'Towr~I'm-l L.OCATION OF DE.A:TH
<br />
<br />Yes [X] No
<br />
<br />Doniphan
<br />9.. RESIDENCE. ST A T[
<br />
<br />
<br />INSIO< CITY LIMITS 8" CO\JNTY OF DEATH"
<br />
<br />Nebraska
<br />10, AAC~ - [e,g" Whili}, Bliir:k, Amefl(:an Indian
<br />elc.1 (SUP-Cltyl
<br />White
<br />
<br />13 NAME OF SPOust: (If Witt:! qlll;:! maicf('rJ r)am~J
<br />
<br />Charles R. Witt
<br />IS, EDUCATION (SpeCify only h'gnestgradf;! comple!e.9_1________
<br />Elementary or Secondary 10, 121 COllegl~ ~ 4 ,."
<br />12 .
<br />
<br />Hi FATHF.R NAME
<br />
<br />14i-1 USUAL OCCUPA TION IG!ve kmdof wo"k dO/IE:! dl,Jring mosl
<br />of wor/(Inq Ilfp., ellen tf t'/Jfrrod!
<br />Homemaker - .
<br />
<br />MIO'OL~r-
<br />
<br />MAIDEN SUHNAMF:
<br />
<br />Own Home
<br />FIRST ~~- lAST~~r;iEA
<br />
<br />_ George_~____ Mllell~_
<br />18 WAS DECEASED EVCH IN u.S, ARMf.O FOR.CES"! .- ~- INf-ORMANT -NAM(
<br />(Yes, no Of unk,1 1lI yes give 1N3r ancl dales 01 services) I
<br />No _____... LJ~l~.!!r1es R. Witt
<br />19b, INFORMANT MAILING AOORESS iSTRFFT OR A F 0 NO CHy OR TOWN STATEllPI
<br />
<br />
<br />220, FUNERAL HOME ADDRESS
<br />
<br />Alma
<br />
<br />Goesch
<br />
<br />68832
<br />
<br />21a M(-T-~<<5D~'Qf DISPOSITION 21b, DATE
<br />
<br />21c CEMETERY OR CREMA-rORY NAMF:
<br />
<br />/I 722
<br />
<br />I!J Bl.trIal
<br />
<br />o AOl!wvClI
<br />
<br />11106/2001 Shickley Public Cemetery
<br />21d CEME:TERY OR CREMATORy LOCATION (:I'U OH 'tOWN
<br />
<br />Sl A T l
<br />
<br />o ("m,,,o, 0 0""'''00 Shickley, Nebraska
<br />ISTREET OR A.F.D. NO CITY OR TOWN. STATE~lIPI--
<br />
<br />1225 N. Elm A ve. Hastings, NE, 68901
<br />
<br />Inlp,rv(l1 between onset anc ':J02.~l'.
<br />
<br /><3 IMMEDIATE CA~J
<br />PAHT
<br />I I" ().M.c.s:u.r-
<br />DUE TO, OR AS A CONSEQUENCE 0'
<br />
<br />o {: ~IENbR l:J~PER, LiNEFOR'I.,lbl AND lell
<br />
<br />Inlp-rll;;!! betweor"\ Or\S~! ar'(~ ~1~i-ll"
<br />
<br />I
<br />~._".
<br />
<br />Ibl
<br />OUe TO. OR AS A CPNSEOUENCI;Q~, .
<br />
<br />Inter\j,J1 between OIlSCl :l~'l: '\'.::l.'
<br />
<br />1'1
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing 10 lhe dealh bul not retaled
<br />PART
<br />"
<br />
<br />26"
<br />0 Accldenl 0 UMelefm,ned
<br />n SUIcide 0 PCM'r"\g
<br />[] i-iOr\'\IC.dH Invesllgalloll
<br />
<br />
<br />25. WAS CA5i= RfFERREO TO MEDICAl
<br />EXAMINER OR CORONFb.
<br />
<br />.;!5_"O~~.
<br />
<br />~c HO~ Oji"'TNJt;tRY
<br />
<br />CITV OR TOWN 5T A T~
<br />
<br />Yes 0 No 0
<br />
<br />27a OATE OF OEA TH {Mo O<l;:~ Yf'/
<br />
<br />\ \ -- \
<br />
<br />
<br />z>
<br />l5.~ ~
<br />I ~ ~ ~ 2& PRONOUNCEQ Of.AO {Mo, Day, Yr J
<br />
<br />p, M' ~ffi~5
<br />
<br />:E. ~ 8 26e. On the basis of exarmnallon and'Or Inllesllgallon. in my opinion dea.lh Oc(a,lrred at
<br />~ ()!5 .. the rune. date and place and due 10 the cau$iC!(SI stated
<br />
<br />~L~_
<br />30> HAS ORGAN OR TISSUF nONATION BEEN CONSIDEReO? 30.b WAS CONSENT GRANTED'
<br />
<br />o YES,_""lQ NO 0 yES
<br />
<br />31 NAME AND ADDRFSS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICiAN OR COUNTY A HORNEYI I Iype '" P,,"')
<br />
<br />i5. ~ lL
<br />H~
<br />!~5
<br />8~
<br />:?~
<br />
<br />29
<br />
<br />David R.
<br />
<br />320. REGISTRAR
<br />
<br />/
<br />
<br />28a, DA rE: 51GNED (Mo,. D~}'Y"Y'0
<br />
<br />I ?8b
<br />
<br />TIME Of DEA lH
<br />
<br />M
<br />
<br />280. PAONQUNCI;:D DI;.AD {HO/,)f/
<br />
<br />M'
<br />
<br />-'
<br />
<br />~NO
<br />
<br />
<br />Hastin s, Nebraska
<br />
<br />68901
<br />
<br />32b DATE FilED By AEGI$TRAR (Mo.. Day Yr.J
<br />
<br />__.1_
<br />
<br />NOV L5.~2001
<br />
<br />Indexed on:
<br />
<br />Lot Sevenl)) and the Easterly Half of Lot Six (6), Block Three 3, GideOllTs
<br />Addition to the Village of Doniphan, Hall Count~, Nebraska.
<br />
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