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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN6-HUMAN 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 STATlST/~~~J1P!'!rj!!.':"CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~~."'-:~~~~...:". _~. ~:o ~""'"
<br />
<br />DATE OF ISSUANCE _. .-:=." .-' p., c~ ~ ~
<br />
<br />JlJll 6 2007 20070629 6 Ails~AN;:::kg~fr
<br />LINCOLN, NEBRASKA HE~rH~~Nii HuMAN=sE~~te~
<br />
<br />--- -' -
<br />-- --..-. .-- - ...-
<br />_._--,--,~'-- -.
<br />STATE OF NEBRASK~~~~:A_:f~~~I~~~f;~N~~U~~N:~~VICES FINA~~f) S---:--,ift~17 0 8 L___
<br />
<br />1. DECEDENT'S-NAME (First,
<br />
<br />MiddlO,
<br />
<br />Last,
<br />
<br />Sulfix)
<br />
<br />2.SEX
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />Willar _______..~Lun
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Springfield. 11
<br />
<br />Sa. AGE.Last Birthday
<br />(Yrs.) 87
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />
<br />11/4/1919
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-09-7604
<br />
<br />8a. PLACE OF DEATH
<br />~:
<br />
<br />~ Inpatlont
<br />
<br />QJJ:!EB:
<br />
<br />1:1 Nursing Home/LTC 1:1 Hospioe Facility
<br />
<br />FACILITY. NAME (If not instilution, gi"fJ slreat and number)
<br />
<br />1:1 ER/Outpationt
<br />
<br />LI Docodonrs Home
<br />
<br />St Francis Medical Center
<br />
<br />I:I~
<br />
<br />o Other (Spocily)
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />ge. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />cj{YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />915 W 3rd
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH 0 Marriod 0 Novor Marriod
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, La't, Suffix) If wife, give maiden name.
<br />
<br />o Divorced 0 Unknown
<br />
<br />Pauline Schwartz
<br />
<br />, 1. FATHER'S.NAME (First,
<br />Robert Lundy
<br />
<br />Middle,
<br />
<br />Last I
<br />
<br />Sulfix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Elizabeth Stuan
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />13. EVER rN U.S. ARMED FORCES? Give dates of service If yes. 14a.INFORMANT.NAME
<br />
<br />(Yes,no,orunk.) No Silk:)1 Remalia
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />GrandDaughter
<br />
<br />15. METHOD OF DiSPOSITION
<br />o Burlat iJ Donation
<br />
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />
<br />16b. LICENSE NO.
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />6/19/2007
<br />
<br />~ Cremation 0 Entombment
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY! TOWN
<br />
<br />STATE
<br />
<br />o Remov.r OOther(Specify) Westlawn Memorial Park Cemetery & Crematory. Grand Island. NE
<br />
<br />'-ia:-F'UNERAL HOME NAME AND MAILING ADDRESS (Stroot, City or Town, Stato) 601 N .--We"bb'-Rd
<br />Livingston-Sondermann Funeral Home. Grand Island. NE
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition resulllng
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />'y
<br />(a)
<br />
<br />,-
<br />L2r~?{ AJ
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />I
<br />I
<br />I
<br />I J".etto de.th
<br />I 4-/'y 0
<br />
<br />re'piralory arrost, or vontricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional line. if nec.ssary.
<br />
<br />Soquontiolly li.t condition.. II
<br />8ny, leading to the CBusl!IlIsted
<br />on line a.
<br />Enterlhe UNDERLYtNG CAUSE
<br />(dl..... or Injury that Initiated
<br />the events resulting in death)
<br />lASf
<br />
<br />~"V""'--
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />,.//10
<br />
<br />I onset to death
<br />I
<br />. : 0.e-0-7~
<br />
<br />~nSOt to death
<br />I
<br />I
<br />
<br />(b)
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />'t- PART II. OTHER SIGNIFICANT CONDITIONS-Condition, contributing to the death but not rosulting in tho undorlying cause given in PART I.
<br />
<br />/.-'. 7AJ
<br />
<br />'''''''AS MEDICAL EXAMINER
<br />OR CORON R CONTACTED?
<br />
<br />iJ YES ~O
<br />
<br />2JCIF FEMALE:
<br />o Not pregnant within past year
<br />o Pregnant a.t time of death
<br />l.J Not pregnant, bUI pregnant within 42 day' of doath
<br />o Not pregnant, but pregnant 43 doy' to 1 year before death
<br />o Unknown if pregnant within the past year
<br />
<br />2'1tWNNER OF DEATH
<br />P N.tural 0 Homicide
<br />
<br />21 b. IF TRANSPORTATION INJURY 2)<WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Suicido 0 Could not be determined
<br />
<br />o Passenger
<br />o Pedestrian
<br />o Othor (Spocify)
<br />
<br />DYES
<br />
<br />"NO
<br />
<br />o AccidentO Pending Investiga.tion
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES [J NO
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY . ~PLACE OF INJ~RYcAt !!QmB.JenIl...lilIelU...ta<:"''lC-'lIfu:<Lhuildingroo"""""",,, silo, ole. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />CfTYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z>
<br />~:!UJ
<br />i~if
<br />i~5~
<br />Etf)2:z
<br />8ffizO
<br />.ll~S
<br />~a:(,)
<br />815
<br />
<br />~. HAS ORGAN OR TISSUE ONATION BEEN CONSIDERED?
<br />
<br />o YES NO
<br />ATTORNEY) (Type or Print)
<br />800 Alpha
<br />
<br />24.. DATE SiGNED (Mo" D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yt.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basIs of examination and/or invBstigation. in my opinion death occurred at
<br />the tims, date and place and due to the cause(s) stated. (Signature and Title) T
<br />
<br />~. WAS CONSENT GRANTED?
<br />Not Applicable if 26a i. NO 0 YES NO
<br />
<br />Grand Island
<br />
<br />NE 68803
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />JUL 2 2007
<br />
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