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<br />a....
<br />",
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANl)H(lMAN SERVICES
<br />SYSTEM, 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 STATISTlCSJ?EPIlQN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~...... ..:....-.'-.-._~~:_.~.;~~....
<br />
<br />DATE OF ISSUANCE ,_. <._.' ",-KJi!f-' _~ -.:_~ '~,
<br />~?-~-" ..' -TANLEY $,'cOdi!ER
<br />
<br />L~~L~, ~E;~2~KA 20070528 4 H~~~~
<br />
<br />
<br />-- -::~':===-i""--- ~---:-"~i
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANGEAND,StJPPORT:'
<br />CERTIFICATE OF DEATH - -
<br />
<br />DECEDENT'S-NAME (First,
<br />Donald
<br />
<br />
<br />
<br />MiddlB,
<br />Lee
<br />
<br />L.st,
<br />Wirtz
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a, AGE.L.st Birthd.y
<br />(Y'",I
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />St. Louis, Missouri
<br />
<br />80
<br />
<br />March 20, 1927
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />6a, PLACE OF DEATH
<br />
<br />493-24-1961
<br />
<br />:aa Inpalianl
<br />
<br />0It:IEB: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />1::lQS,eJ.TAJ.:
<br />
<br />FACILlTY.NAME (If nol institulion, give streel and number)
<br />
<br />CJ ER/Oulpalianl
<br />
<br />o Decedent's Home
<br />
<br />Saint Francis Medical Center
<br />
<br />1J0Cl'\
<br />
<br />IJ Other (Specify)
<br />
<br />6c, CITY OR TOWN OF DEATH (Include Zip Codal
<br />
<br />Grand Is:J,p.n~~__
<br />9a, RESIDENCE.STATE
<br />
<br />6d, COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9b, COUNTY
<br />
<br />
<br />9g, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />_.-Ha
<br />
<br />9d, STREET AND NUMBER
<br />
<br />6 8 8 Q.1__m.___
<br />
<br />o Nev.r Marrl.d lOb, NAME OF SPOUSE (First, Middla, Last, Suffix) It wit a, give maidan nama,
<br />
<br />IJ Marrl.d, buts.paratad 0 Widowad 0 Divorcad 0 Unknown Marian Wirtz
<br />
<br />11, FATHER'S-NAME (First,
<br />Oscar
<br />
<br />Middla,
<br />
<br />L'SI,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (Firat,
<br />Ida
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Ebinger
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />
<br />CITY / TOWN
<br />
<br />13, EVER IN U,S, ARMED FORCES? Glv. dales of .ervice if yes. 14a,INFORMANT.NAME
<br />(Y.',no,orunk,) No Marian Wirtz
<br />15, METHOD OF DISPOSITION
<br />
<br />16b, LICENSE NO.
<br />/0-7,/
<br />-- ~,~_._-,_._,,--~.
<br />
<br />16c, DATE (Mo" Day, Yr. )
<br />May 18, 2007
<br />
<br />STATE
<br />
<br />IJ Buri.1
<br />
<br />IJ Donation
<br />
<br />:Ill Cr.m.tion CJ Entombment
<br />
<br />o Ramoval 0 Othar (Spacity)
<br />
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAiliNG ADDRESS (Slr..I, City Or Town, SI.ta)
<br />
<br />PART I. Enter the chAin of p.Vp.nI5--diseases, irijuries. Or complications--that directly caused the dea.th. DO NOT enter terminal events such as cardia.c arrest,
<br />re'pir'lory arrest, or vanlricul.r tibrillafion wilhout showing the .tiology, DO NOT ABBREVIATE, Ent.r only on. c.us. on a IIn., Add .ddlllonalIIn..If n.c....ry,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsat to da.th
<br />
<br />(.)
<br />
<br />(tE.s/1 Mf'i1.( ";(
<br />
<br />
<br />... .Ar~aA.L.
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... otcondttlon nlSUlllng
<br />In death)
<br />
<br />Sequ.ntl.lly 11., condlllon., II (b).. L!. i!L lAA.. II'\J NT/.}
<br />.ny, laadlng 101he causa IIsled --DU'e:'rO:"OR AS A CONSEQUENCE OF:
<br />on line a.
<br />En1ertho UNDERLYING CAUSE
<br />(dl..... or Injury th.tlnlll.ted (c)
<br />the .y.ma resulting In death)
<br />LASf
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I on.atto death
<br />
<br />10 "4if'
<br />
<br />ons.t to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.t to death
<br />
<br />(d)
<br />18 PART il-OTH'ER SIGNIFICANT CONDITIONS-Conditions cont"buling to the d.alh but not rasulllng In Ih;'~nd~r~I~Q~;''-;Q-;';;-n "PART I""' ,._--~" ,. "O-19-WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />__S:_~!'" srrt/t Hl..M.r />ff4ll'f-l . ___,,__~_"______" ~ YES NO
<br />21 c' WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />
<br />21 a, MANNER OF DEATH
<br />o N.tur.1 IJ Homicide
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Drlv.r/Op.rator
<br />
<br />o pa.seng.r
<br />
<br />o Padestri.n
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o Not pr.gnant within p.st y.ar
<br />IJ pr.gn.nt .lIim. ot dealh
<br />o Not pragnanl, bul pragn.nt within 42 d.ys of d..th
<br />o Nol pragnanf, but pregn.nt 43 d.ys to 1 y..r b.for. d..th
<br />IJ Unknown if pr.gnant wllhln Iha p.st year
<br />
<br />Jii( N 0
<br />
<br />DYES
<br />
<br />o AccidantD Panding Inv.stlg.tion
<br />Cl Sulcid. 0 Could not b. determined
<br />
<br />U Oth.r (Sp.clfy)
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />22., DATE OF INJURY
<br />
<br />
<br />R~CE~Q.________
<br />
<br />STArE ZIP CODE
<br />
<br />_~-JUtLl" If 07
<br />
<br />24', DATE SIGNED (Mo" D.y, Yr.) 24b, TIME OF DEATH
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-AI hom., farm, .tr.et, faclory, office building, constructi~n_~:.a~:(~peclfy)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />IJ YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYiTOWN
<br />
<br />')
<br />~
<br />
<br />23., DATE OF DEATH (Mo" D.y, Yr.)
<br />152007
<br />
<br />
<br />(,
<br />
<br />m
<br />
<br />~~~
<br />H~
<br />o.D. CC ~
<br />Eln[:z
<br />815,.0
<br />.8255
<br />{2rr.U
<br />o ~
<br />00
<br />
<br />23c, TIME OF DEATH
<br />04:37 A.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 t~time, date and place
<br />and due to Ih.~') stated<o(:jlryalure and i "
<br />
<br />X-J~A-
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the tim., d.t. .nd pl.c. .nd due to the cau..(.) st.l.d, (Signa lure and Title) "
<br />
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />~_~__~., [JPR_~BABLY 0 UNKNOWN 0 YES ~
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Print)
<br />David R. Colan M.D. 729 N. Custer Ave. Grand
<br />
<br />28., REGISTRAR'S SIGNATURE
<br />
<br />26b, WAS CONSENT GRANTED?
<br />NOI Applic.ble if 26a Is~? [J_Y~S_ .J!rNO
<br />
<br />Island
<br />
<br />Nebraska
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />MAY 2 1 2007
<br />
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