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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE QA - VHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE WR JUL 1 9 2007 2007082,12 = � TANS. cock. AS @4T9N F7YFF ftIST14€ LINCOLN, NEBRASKA HEABTW AN"ormAmrst-RVICE STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES fN{•f�f(i�$UA n CERTIFICATE OF DEATH - `� '2 7 5 9 9 I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (MO., Day, Yr.) _Anita Louise female 5c. UNDER 1 DAY Jul 11, 2007 6. DATE OF BIRTH (Mo., Day, Yr.) _Thesenvitz 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR MOS. DAYS HOURS MINIS. (Yrs,) Comstock, Nebraska 85 March 5, 1922 ....- -- 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH 048-10-4885 HOSPITAL: 0 Inpatient QAiE& ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER /Outpatient 1�I Decedent's Home 8b. FACILITY -NAME (If not institution, give street and number) 11100 W. Husker Hwy. ❑ roe, ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) _ 8d. COUNTY OF DEATH Wood River 68883 -� Hall 9a.RE5IDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN -. Nebraska Hall Wood River 9d. STREET AND NUMBER 9e. APT. NO 9f, ZIP CODE 9g, INSIDE CITY LIMITS 11100 W. Husker Hwy. 68883 ❑ YES lX NO 10a. MARITAL STATUS AT TIME OF DEATH Marrled ❑ Never Married , 10b. _ NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ❑ Married, but separated []Widowed ❑Divorced ❑Unknown Elmer August Thesenvitz 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frank Roach Lola Messersmith - 13. EVER IN U.S. ARMED FORCES? Give dates of service It yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT (Yes,no,orank.) -No Robyn Couch daughter 15. METHOD OF DISPOSITION 16a. EMBALMER - SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. ) ABurial ❑Donation Not Embalmed July 13, 2007 ❑Cremation ❑Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE ❑Removal ❑Other(Specify) Grand Island City Cemetery, Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code �V All Faiths Funeral Home, 2929 S. Locust St.Grand Island, NE 68801 18. PART I. Enter the chain of events--dissases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death (n" IMMEDIATE CAUSE (Final (a) �� Pt, ` , 31',o w f disease orcondiGonresulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death in deem) Sequentially list conditions, it (b) I any, leading totecauselated -DUE TO, ORASA CONSEQUENCE OF, I onset to death on line e. Enter the UNDERLYING CAUSE (disease of Injury that Initiated (c) the events resulting indeath) DUE TO, OR ASA CONSEQUENCE OF: I onset to death LAST I (d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I. , WAS MEDICAL EXAMINER OR CORONER CONTACTED? L ^T 421c. ❑ YES XNO 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJAUTOPSYPERFORMED? <Not pregnant within past year lk"r -ral ❑ Homicide \ ❑ Driver /Operator NO ❑ Pregnant at time of death ❑Accident❑ Pending Investigation ❑Passenger CI Not pregnant. but pregnant within 42days ❑Suicide ❑Couldnotbedetermined ❑ Pedestrian 21d .WEREAUTOPSYFINDINGSAVAILABLETO ❑ Not pregnant, but regnant 43 days to 1 year before death A P before ❑Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Unknown if pregnant within the past year ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m - 22c. PLACE OF INJURY-At home, term, street, factory, office building, construction site, etc. (Specify)- - 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED - U YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE _ ZIP CODE W 23a. DATE OF DEATH (Mo., Day, Yr.) z r 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH a s� Jul 11 2007 �5'z m b. DATE SIGNED (MO., Day, Yr.) 23c.TIME OF DEATH r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD El z -� 8:45 p. m a�a? m 0 C 23d. To the best of my knowledge, death occurred at the time, date and place 8 w 24e. On the basis of examination and/or investigation, In my opinion death occurred at and due to the c use(s) stated. (Signature and Title ) ♦ o the ilme, date and place and due to the cause(s) staled. (Signature and Title ) � r�o 25. DID TOBAr(n UUSE CO RIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? El YES ,;.' NO ❑ PROBABLY_ ❑ UNKNOWN ❑ YES NO Nat Applicable if 26a is NO ❑ YES 0 _- 27. NAME, TITLE AND ADDRES OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) _ imberly MicK&els, M.D., 729 N. Custer Ave.,Grand Island, Nebraska68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,) 1 JUL 1.7 2007 I