|
<br />STATE OF NEBRASKA
<br />
<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 RECOBD. ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS.,t:EC.THlt(#!J!tql IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. k ~if{!i;'~--\'-,-
<br />
<br />
<br />DA~EOCF IS2SUgAN2COOE5 ""V-r:7J~~EY s. coop~~'?i
<br />ASSISTANT STATE REGISTRAR:
<br />LINCOLN, NEBRASKA 2 0 0 7 0 5 0 1 2 HEALTH.ANQ HUMAN SERV!Ct!~-{
<br />
<br />~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND'SUP~O. RT..,. 'n.".I.:;. -".-'?'l' . 4 380
<br />CERTIFICATE OF DEATH ., <:CUv
<br />- --- "".,,_.__...._---~ .-_..~._"'.,.~.__...............~. ~
<br />
<br />DECEDENT'S.NAME (Firsl,
<br />James
<br />
<br />Middle.
<br />Allan
<br />
<br />Last,
<br />Wentz
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF D~ATH (MO., Day, Yr.)
<br />December 3, 2005
<br />
<br />North Dakota
<br />
<br />56
<br />
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Lasl Birlhday
<br />(Yrs.)
<br />
<br />February 22, 1949
<br />
<br />7. SOCIAl SECURITY NUMBER
<br />470-54-5866
<br />
<br />8a. PLACE OF D~ATH
<br />!:illill'JJI\L: U Inpaliont
<br />
<br />QI!:i!:B: CJ Nursing Horne/LTC CJ Hospice Fecillly
<br />
<br />8b. FACILITY-NAME (If not in::;titullon, give street and number)
<br />
<br />___,_J_._
<br />
<br />o ER/Oulpalient
<br />
<br />Dl Decedenl's Home
<br />
<br />LJ[O\
<br />
<br />U Olher (Speclly)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF D~ATH
<br />Grand Island, 68801 Hall
<br />
<br />~;~;:~~:TE _~~ =-t~:::W~sland ----~..
<br />
<br />9d. STREET AND NUMBER .-.,..- - ---.1 9~-AP-T'~ 9f ZIP CODE ~IDE CITY LlMITS-
<br />2504 Parkv:~~~ Dri~.l:__~__.___".. '" ____--"-__..1 6880_~ _.~.~._.L_plI"~:s CJ NO
<br />10a MARITAL STATUS AT TIME OF DEATH Jl{Marrled 0 Novar Marrlod 110~ NAME OF SPOUSE (Fllst, Mlddlo, Lasl, Suffix) If wlfc, give maiden name.
<br />
<br />o Married, but seperated 0 Widowed 0 Dlvoroed 0 Unknown LArmandina Sanche z
<br />
<br />FATHr:R'S.NAME (Firsl, Middle, 'Z~ -Sulllx) 112'MOTHER'S'NAME (Flrsl,
<br />Gary Wentz Irene
<br />""'''''.'~.~'.",,-,.. .'.....---'.,
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Rustad
<br />
<br />o Burlel
<br />
<br />
<br />Sanchez-Wentz
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dale, of ,ervlce if yes.
<br />(Yes, no, Dr unk.) No
<br />
<br />rlCromation 0 Enlombment
<br />
<br />-ATION
<br />
<br />16b. LICENSE NO.
<br />
<br />/, 9 (
<br />
<br />CITY /TOWN
<br />
<br />16c. DATE (MD., Day, Yr.)
<br />Dec 10, 2005
<br />
<br />STATE
<br />
<br />15. METHOD OF PISPOSITION
<br />
<br />16a.
<br />
<br />o Donation
<br />
<br />o Romoval OOlhor(Sp.clfy) Westlawn Memorial Park
<br />___~_,~_g:r~ma_~.9.rY
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Cily or Town, SI.I.)
<br />Livingston- Sondermann Funeral Home 601
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />18. PART I. Entfif Ihe ~oil.in or evanls--diseases, injurios, or compllcations--that directly caused the dealh. DO NOT enler terminal events such as cardiac arrasl,
<br />respiratory arrest, or ventricular rtbrillallon wlthoLlt showing the eHology, DO NOT ABBREVIATE, Erller only one causa on a line, Add addillonallines H necessary.
<br />
<br />
<br />IMMEDIATE CAUSE (Final
<br />dIsease or condItion resulting
<br />In deeth)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />__~__ C y~cJj..9)1:\P~.q.. L\4_.~ ~ \t '}\1\.Q~~~ ~.CQfQ!l~X~QI[ W
<br />DUE TO, OR AS A CONSEQUEf'kE OF: ,
<br />
<br />
<br />onsello (leath
<br />
<br />onsello death
<br />
<br />Sequen1ially Ii~t conditions, if
<br />.ny, le.ding 10 the ".u.ellsted
<br />on Iln~ a,
<br />Enterlhe UNDERlYING CAUSE
<br />(dise!.se or Injury that Initiated
<br />tM events TBsuUing in death)
<br />l.ASr
<br />
<br />(oj
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 dealh
<br />
<br />(c)
<br />. DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />.~
<br />onsclto death
<br />
<br />(d)
<br />
<br />PART II. OTHEn SIGNIFICANT CONDITIONS.Cunditlun' cont'ibuling 10 Ih. death bUI nol ,esulllng In the underlying co,,,. given in PART I.
<br />
<br />1Q. WAS MEDICAL EXAMINER
<br />
<br />OR CORDNER CONTACTeD?
<br />
<br />III YE S
<br />
<br />o NO
<br />
<br />20, IF FEMALE:
<br />o NOI pregnanl within pMt yeat
<br />o Pregnanl at lime 01 dealh
<br />o No! pregnant, but pregnant within 42 days of death
<br />o Not pregnant, bul pregnant 43 days 10 1 year before death
<br />o Unknown II pregnanl wllllln Ihe pest year
<br />
<br />210. MANNER OF DEATH
<br />l(Na.lural 0 Homicide
<br />
<br />III YES 0 NO
<br />
<br />o AccldenttJ Pending Inve,lIgalion
<br />
<br />21b.IFTRANSPORfAJION INJURY
<br />o Drlver/Ope'elor
<br />
<br />lJ Passenger
<br />
<br />o Pedestrian
<br />
<br />U Other (Spacily)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o Suicide 0 Could rIOl be deierrnlned
<br />
<br />21d. WERE AUTOPS-Y FINDINGS AVAII.ABI.UO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />DYES 0 NO
<br />
<br />
<br />~ YES
<br />
<br />UNO
<br />
<br />22a. DATE OF INJURY (Mo., Doy, Yr.)
<br />
<br />22b. liME OF INJURY
<br />
<br />22,. PL~C~~JU_R~.AI hom!0'O''!:', .lrO?I, f~orl, office building. cQ~strrJclliL~.~, .!o.(Spedr},)__._
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LO~ATI()N or IHJi"JnY. STREETS. NUM::!r::.n, ArT. NO.
<br />
<br />CtT'(,TOWN
<br />
<br />STATE
<br />
<br />ZH" CODE
<br />
<br />230. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />12/20/2005
<br />
<br />24b. TIME OF DEATH
<br />unknown
<br />
<br />m
<br />
<br />m
<br />
<br />Z>
<br />~~;g
<br />-oing5
<br />-ll~f:
<br />1i11.~~
<br />E.(I) >- z
<br />" c:. ~~ Ci
<br />"uJZ
<br />"z::>
<br />"'00
<br />~a=U
<br />o ~
<br />U 0
<br />
<br />
<br />24d. TIME PRONOUNCED DEAF 0 U n d
<br />6:00 P m
<br />
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />._,~
<br />23d. To the Desl cf my knowledg.. dealh occurred at Ihe limo, dOle and place
<br />
<br />and due 10 Ih. cause(.) Slated. (Signa lure and Title) ,.
<br />
<br />240. On the ,0 ~ ,". inatioh and/or investigalion, In my opInIon death occurred at
<br />the I ,val:8 ,aco and due \0 Ihe cau.e(s) Slaled. (Signalllre and Title)"
<br />
<br />._ ,r:
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YeS ~ NO 0 PROBABLY 0 UNKNOWN CJ YES NO
<br />27. NAME, TITLE AND AiioRESS OF CERi'iRE'Fi-(pf-!vsiClAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Robert E. Bowen MD Coroner's Ph sician
<br />
<br />26.. REGISTRAR'S SIGNArURE
<br />
<br />
<br />No. Appllcoble II 26a i, NO 0 YES 0 NO
<br />909 Civic Center
<br />Omah NE 68183
<br />
<br />2Bb. DATE FILED BY REGISTRAn (MD., Day, Yr.)
<br />
<br />DEe 2 7 2
<br />
|