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<br />STATE OF NEBRASKA
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<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 R'I~glJlr;u.E.~WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST{[;$~TJt!N(WHJ.~/S ..
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<br />:~::~::~:;TORY FOR V"AL RECORDS . ~l~iR
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<br />DEe 2 8 2006 ASSISTANrSTATEREG/S-1;R1R';
<br />LINCOLN, NEBRASKA 200704711 HEALrHAND-HIiJMAt($EF!J'ICE$:
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<br />STATE o~ NEBRASKA - _DEPAR~~~;tf~cr;~N~t~~N:~~VICESFI:A~CE AND SUPPo~6 3 4iL3L
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<br />1. DECEDENT'S,NAME (Flrsl, Middle, Last, Suttlx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Sam N. Wolbach Male ecember 17,2006
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<br />4 CITY AND ~TATE OR TER~'~ORY, OR FOREIGN COUNTRY OF BI:=r:TH~ -- 55 AGE-Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" Day, Yr.)
<br />Chicago, Illinois (Y15) 89 MOS. DAYS HOURS MINS. March 16, 1917
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<br />7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
<br />511-18-5681
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<br />DUE TO, OR AS A CONSEQUENCE OF:
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<br />o Inpatient
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<br />H.Q.S!'lIAI.:
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<br />illI:JEB;
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<br />o Nursing Home/LTC 0 Hospice Faclnly
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<br />8b. FACILITY-NAME (If not Institution, glva .treet and numbor)
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<br />o ER/Outpatlent
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<br />~ Decedent's Homa
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<br />2617 Apache Road
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<br />U D:l'\ OOther(Specity)_.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda) 1Bd:C6UNTY OF DEAT.H
<br />Gran~__IslarJ.!!.tNebr~~~9-~El._?93 '. .1_ . Hall
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<br />~a~~;E;c;-~:E ~~:TYIl~~~~OW;sland --
<br />-;d~;R;TA:;U~~~e Road'--- ---- ...- -~P~.~N_O- 91.~I~C;D~3--~~~~;:CITY~'M~:-
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<br />lOa. MARITAL STATUS AT71MEOFDEATH Xl Married 0 Never Ma"ied lOb. NAME OF SPOUSE (First, Middle, Le.t, Suffix) It wlta, give melden nama.
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<br />o Married, but separaled 0 Widowad 0 Divorcod U Unknown
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<br />Gloria Gray
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<br />11:FATHER'S-NAM-~;~i~_~::~' woLi6~ach SuttiX)E~:S~~A~e~l~tett_e'"
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<br />13. EVER IN U.S. ARMED FORCES? Give dala. ot sarvice il ye.. 14a. INFORMANT-NAME
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<br />(Yes,no,orunk.) No Gloria Wolbach
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<br />Middle. Maiden Surname)
<br />Pettinger
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<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
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<br />16.a.EM~ER-SIGN. .lirUR~1' C;V.. .. +'.
<br />( .'M Wf o'l, Q).j..{~
<br />l'6d. CEMETE-RY, C;{JMATORY OR OT~'ERl CATION
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<br />16b. L1C~NSE NO.
<br />1328
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<br />16e. DATE (Mo., Day, Yr.)
<br />ecember 21,2006
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<br />o Donation
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<br />U Enlombmonl
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<br />CITY / TOWN
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<br />STATE
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<br />o Other (Spaclly)
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<br />Grand Island City Cemetery, Grand Island, Nebraska
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<br />_ 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, St.te)
<br />All Faiths Funeral Home, 2929 S. Locust
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<br />PART I. Enter the Qhaln...Qf..e:~--disBasas, InJuries, or complica1lons--lhat directly caused the death. DO NOT enter terminal events such as cardiac arresl,
<br />resplralory arresl, or venlricular Ilbrlllatlon wlthoul.howlng Ih. etiology. DO NOT ABBREVIATE. Enter only one cause on e line. Add additlonalllMs If nec.ssary.
<br />IMMEDIATE CAUSE:
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<br />onset to death
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<br />Cardiac arrest
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<br />immediate
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<br />(a)
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<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
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<br />I ons.t to dealh
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<br />S.quentlallyll.lcon~ltlons,lf (b) co_mQl icatt9ns of neck cancer I months
<br />any, 1..~lng lotheceuaallsl.d DUE TO, OR AS A CONSEQUENCE OF: I on,ello doath
<br />onllnea. I
<br />EnlertheUNDERlYING CAUSE I
<br />(dl..... or Injury that inltlal.d (c) . .!-
<br />Ihe evenls r..ultlng in deeth) DU" TO OR AS A CONSEQUENCE OF d h
<br />131\', ..; lAST C ,; : onsaI to eet
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<br />:.f.'I.'~.;,....; 18 PART" OTHER SIGNIFIC;N~ONDITIONs-condllio~s contributing 10 t';;,je;;ih but not resultmg in the~~derIYlng CaUSe glvO~PART '~9IWAS MEDICAL EXAMINER
<br />; '1'\'1 OR CORONER CONTACTED?
<br />I'>,J----.b.~a.rt disease ___ _ _ _)Q YES 0 NO
<br />;:"1-11' 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />'.'~ k~' [J NOI pregnant wilhin past yaar :*l Nalurel 0 Homicid. ~ ~:'::~:~:~rator LJ YES O:NO
<br />..:;t4),-:]i 0 Pregnant al1ime 01 dealh U AccidsntO Pending Investigation
<br />/c~: 0 Not pregn.nl, bul pregnant within 42 d.ys of death 0 Suicide 0 Could not be determin.d 0 Pedastrl.n 21d. WERE AUTOPSY FINDINGS AVAILA8LE TO
<br />';;ii:~ 0 Not pregnant, bUI prBgnant43 d,yslo 1 year beloro death W Oth.r (Speolfy) COMPLETE CAUSE OF DEATfl?
<br />,:\ ", U Unknown II pregnanl within Iha p.s' yaar U YES ~ NO
<br />2i; BAT" OF INJUHY (Mo , Day, ~2b.mTIFTNJlJR:. r22~LAC=E-OFINJURY:-At hom., f;;r~~str.at~ctory, offl~;;-b~lidlng, co~.truetlon .ile, ~IC (~P~~'IY)
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<br />22d INJURYATWORK? ]22e"' DESCRIBE HOWfNJlJRYOCCURRED-- -- - --- ---- - ----
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<br />221. LOCATION OF INJURY - STREET & NUM8ER, APT. NO. CITYfTOWN STATE ZiP CODE
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<br />23a. DATE OF DeATH (Mo" Doy, Yr.)
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<br />24e. DATE SIGNED (Mo" Day, Yr.)
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<br />21..
<br />240. PRONOUNCED DEAD (Mo" D.y, Yr.)
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<br />24b, TIME OF DEATH
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
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<br />23c. TIME OF DEATH
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<br />23d. To the best 01 my knowledge, dea1h occurred at Ihe lime, dale and place
<br />.nd dua to tha causals) slatad. (Slgnalure and Titl.) l'
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<br />25. DID TOBACCO USE CONTRiBUTE TO THE DEATH?
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<br />26a. HAS ORGAN OR TISSUE DONA~ 0
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<br />__ []__~_O_..__O PROBABLY_.ctUNKNOWN .[]_~~. ~ NO _.. _ NO,I Applicabl. il26a is NO 0 YES 0 NO
<br />27. NAME, TiTLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Print)
<br />L nelle Homolka, De uty Hall County Attorney 231 S. Locust Street Grand Island NE 68801
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<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />[lEe 2 6 2006
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