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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANDI-!IJAjlAl'L~f.'iVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL~r:oRD~€}N:-fl~Ei'(lITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISI!_~S SijtCTJP.ui'W14If'((S
<br />
<br />:::~::~~:::::~TORY FOR VITAL RECORDS'~..-.~,Yj....'..'_._.&j)..-?il:7!iJf..'== '.- ~:. -~'_-'{.:.\
<br />"""'1~ "TitfANi.'e)iS.l;tJd?ER:~'
<br />DEe .2 8 2006 ASSOm- STATE REqlsiRAFJ/
<br />200700280 HEAL~~~~~~~~~/5EJ
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />'"",
<br />
<br />
<br />STATE O..F NEBRASK.. A.. -.. D.. EPARTMENT 0... F.HEALTH AND HU...M.AN SERVICES FINAN. CE-ANPSljpp6~ 6. .'. "} 4 no 3 ' 3
<br />____~_____ CERTifiCATE Or:_.r;lFATH _ _ . ", .,~. _" _~_____
<br />1. DECEDENT'S-NAME (First, Middle, Lasl, Suffix) 2. SEX 3. DATE OF DEATH (MO., Day, Yr.)
<br />Sam N. Wolbach Male ecember 17,2006
<br />
<br />, "" '"" ""CO; ;," mm"" ""''''''' CO"",", "'"'"" F;~' ;..""".., " "'"' """" ""'"'" , "" , """ "' "'"" ,"0, "", "I
<br />Chicago, Illinois (Yrs) 89 MOS. DAYS HOURS MINS. March 16, 1917
<br />
<br />-- ---- ~- -~-
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />511-18-5681
<br />
<br />~:
<br />
<br />o Inpatient
<br />
<br />illliE.B:
<br />
<br />o Nursing Home/LTC 0 Hospice Facilily
<br />
<br />Bb. FACILITY-NAME (II not Inslltullon, give str..t and numb.r)
<br />
<br />
<br />U ER/Oulpallenl
<br />
<br />:KI Decedent's Home
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Islandl Nebraska
<br />~a;~~E;c~-~:E ----- J-9b C~~TYll
<br />
<br />68803
<br />
<br />U ro\ 0 Olher (Sp.cily)
<br />/Sd:COUNTY OF DEAT~, Ha 11
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />_ __ _ __ -- -1ge. APT NO __J-916ZIPSCSODOE 3 ___
<br />2 61? Apach~_Road_ .. L
<br />
<br />'" "",,^' """' .n,",", "'''" Xl ",moO U """ ""'~ I '"" ~"' oc """" ","" "~', "", ""oJ" ."" "" """. ..,,',
<br />
<br />LJMarrled,bulseparaled OWldowed ODivo,oed OUnknown Gloria Gray
<br />
<br />11. FATHER'S-NAME (First, Middle, LaSI, Suffix) 12. MOTHER'S-NAME (First, Middle, . Maiden SUrname)
<br />Edwin J. Wolbach Jeanette Pettinger
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />13. EVER IN U.S. ARMED FORCES? Giv. dales 01 servloe il y.s. 14a. INFORMANT-NAME
<br />(Yes, no, orunk.) No Gloria
<br />15. METHOD OF DISPOSITION
<br />Xl Burial Ll Donation
<br />
<br />Wolbach
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
<br />
<br />o Cremallon U Entombmenl
<br />
<br />1 Ba. EMBAL "R-SIGNATUR:/ G'V't
<br />./Ul C-LiI dl, !:J.>>-- ~
<br />16d. CEMETERY, CFaMATORY OR OTHER L CATION
<br />
<br />16b. LICENSE NO.
<br />1328
<br />
<br />18c. DATE (Mo., Day, Yr.)
<br />ecember 21,2006
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />o Removal 0 Olher (Speolly)
<br />
<br />Grand Island City Cemetery, Grand Island, Nebraska
<br />
<br />PART I. Enl.r th. ~y~.--dlseases, injurie" or oompllcatlonsulhal dlreolly oaused Ihe death. DO NOT enl.r lerminelevents suoh as cardiao arresl,
<br />respiratory arrest, or ventricular fibrillation wllhoul showing the etiology. DO NOT ABBREVIATE. Enter only one cause on e line. Add addi110nalllnes II necessary.
<br />
<br />
<br />
<br />_ 17a. rUN"RAL HOME NAME AND MAILING ADDRESS (Slreet, City or Town, Slele)
<br />All Faiths Funeral Home, 2929 S.
<br />
<br />St.,Grand Island, NE
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMM"DIATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMM~OIA TE CAUSE (Fln.1
<br />disease or conditIon resulting
<br />In death)
<br />
<br />(aJ Cardiac arrest
<br />
<br />immediate
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />S.qu.ntlally list conditions, It
<br />any, leading to the cause listed
<br />on line s.
<br />Ent.r th. UNDERLYING CAUSE
<br />(dl..... or InJury that initiated
<br />Ihe .venls resulting In d.ath)
<br />lA'lT
<br />
<br />(b) complications of neck cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />months
<br />
<br />onsel to death
<br />
<br />(c)
<br />
<br />---,-,
<br />DUE TO, OR AS A CONSEQUENC" OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OHlER SIGNIFICANT CONDITIONS-Condillons oonlrlbullng 10 the dealh bUI not resulllng in Ihe underlying cause given In PART I.
<br />
<br />20. IF FEMALE:
<br />
<br />21 a. MANNER OF DEATH
<br />%I Natural 0 Homlolde
<br />
<br />o AccidenlO Pending Invesligalion
<br />
<br />o Suicide 0 Could not be dol.rmined
<br />
<br />21 b.IFTRANSPORTATlON INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o P.de'trlan
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />)(j YES 0 NO
<br />
<br />210. WAS AN AUTOPSY PERFORMED?
<br />
<br />heart disease
<br />
<br />[J Not pregnant within past year
<br />[J Pregnant allime 01 death
<br />o Not pregnant, bUI pregnant within 42 days of dealh
<br />o Not pre9nanl, bul pregnant 43 days 10 1 year belore dealh
<br />U Unknown iI pregnanl within Ihe pasl y.ar
<br />
<br />W YES
<br />
<br />ClNO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />22e. DATE OF tNJURY (Mo., Day, Yr.)
<br />
<br />COMPLETE CAUSE OF DEArH?
<br />o YES ~ NO
<br />22b.--iIMEO'F INJi.jRy~12kPLACE OF INJURY.AI hO~., larm, Slreet, lactory, OIli~;;'lIlldlng, conslruclion ~i;';:~lO. (Speoily)
<br />~~I
<br />-..- - .'-.'.'''--'" .- ". . ..-.
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Other (Specily)
<br />
<br />22d.INJURY AT WOnK?
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION or INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />ST/IJE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />
<br />m
<br />
<br />z>
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<br />lil:~~
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<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />l)p.cp.mhp.r21...
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO HIE DEATH?
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONA" 0
<br />
<br />
<br />_2330
<br />
<br />m
<br />
<br />23b. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />230. TIME OF DEATH
<br />
<br />23d. To the best 01 my knowledge, death occurred al ths1ime, date and place
<br />and due 10 Ihe cau,e(,) slaled. (Signalure and Tille) "
<br />
<br />_O_~_~c:._ 0 PROBABLY__~~~N._~ 0 YES.. ~ .N<.J._ Not Applloab_~ if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />L nelle Homolka, De uty Hall County Attorney 231 S. Locust Street Grand Island NE 68801
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEe 26 2006
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