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<br />
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSL~c,.''f!;!JCH IS
<br />
<br />::::::~::;TORY FOR VITAL RECORDS ~l!~~
<br />MAY 1 0 2007 2 0 0 7 0 9 3 3 8 ASStsTANr:~iEi8m/stRAFt
<br />HEAilrH;ANI5-HtniAti:SE1:l\iJGES~
<br />'c'_ -""~"- """ j '= _~i
<br />-- ~--:~~~~~=~~~~:-,~-~-- - -~_.
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTHAND HUMAN SERVICESFINAN9!}~Do~I,J~~--,,~"~ 9 8 7
<br />.... .. CERTIFICATE OF DEATH -_"O,-==o;I.J,t~> l:._
<br />
<br />.i.-r"
<br />
<br />~..
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />DECEDENT'S.NAME (First,
<br />Donna
<br />
<br />Middle,
<br />
<br />S.
<br />
<br />Last,
<br />Wernke
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr.)
<br />Apr~l 30, 2Q~
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />9a, RESIDENCE.STATE
<br />Nebraska
<br />
<br />L""
<br />
<br />5a, AGE.Last Birthday 5b, UNDER I YEAR 5c, UNDER I DAY 6. DATE OF BIRTH (Mo., Day, Yr,)
<br />(Yrs) 77 MOr HOURS MINS.
<br />
<br />
<br />J;;;,o"~m .
<br />l:I.llSflIAL: 0 Inpatient QJJ:IEB; Xl Nursing Home/LTC 0 Hosploe Facility
<br />
<br />o ER/Outpallent 0 Decedenl's Homa
<br />
<br />o C(lII. 0 Other ISpecity)
<br />
<br />. - '--/:OUNTY OF DEATH
<br />
<br />Hall
<br />90, CITY OR TOWN
<br />Grand
<br />
<br />June 30,
<br />
<br />1929
<br />
<br />Hastings, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />505-34-0510
<br />
<br />5b, FACILITY.NAME (If not institution, give street and number)
<br />
<br />Beverly Heathcare: Park Place
<br />
<br />5c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />Hall
<br />
<br />
<br />9f, ZIP CODE
<br />68801
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />)afI YES 0 NO
<br />
<br />9d, STREET AND NUMBER
<br />210 East Charles
<br />
<br />I Oe, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Nevar Married lOb. NAME OF SPOUSE (FirS!, Middla, Last, Sufllx) It wife, give melden nama.
<br />
<br />o Marri.d, but ..par.t.d IXl Widowed 0 Divorcad 0 Un~nown
<br />
<br />11. FATHER'S-NAME IFir.t,
<br />Alvin
<br />
<br />Middle,
<br />
<br />L.st, Suffix)
<br />Schuck
<br />
<br />12. MOTHER'S-NAME (First,
<br />Clara
<br />
<br />Middle,
<br />
<br />M.id.n Surname)
<br />Kloke
<br />
<br />13. EVER IN U,S, ARMED FORCES? Giv. d.t.s of service if y.s. 14a, INFORMANT-NAME
<br />No Gwen Reed
<br />
<br />o Cr.matlon 0 Entombment
<br />
<br />16a, EMBALMER'SIGNATU~ ~
<br />
<br />
<br />16d, CEMETERY, CREMATORY OR OT
<br />
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />IS, METHOD OF DISPOSITION
<br />M Burial 0 Donation
<br />
<br />16b. LICENSE N~
<br />/$Z.r
<br />
<br />16c. DATE (Mo., D.y, Yr,)
<br />May 4, 2007
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />o R.moval 0 Oth.r (Specify)
<br />
<br />Grand Island Cemetery
<br />
<br />Grand 'Island,
<br />
<br />----.,
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (SIr..t. City or Town, St.t.)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />PART 1. Enter the chain nf Aventsndiseases, InJurie$, or compllcatlons.:that.9tre~t1y._cau8Bd th.!uiaalh. OO.~'entei'te'fmlnalevents suCl1 as cardiac arrest,
<br />respiratory arre't, or ventricular fibrill.tion without .howing the .tlology, DO NOT ABBREVIATE, Enter ooly on. cause on elln.. Add addlllonellln.. if n.cessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to de.th
<br />I
<br />--.!;d~
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condlUon resulting
<br />'n daeth)
<br />
<br />la) ~ t:'_A? . ...... I':
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />ons.t to deeth
<br />
<br />Sequ.ntlally lIal condillon., II (b). . 5~ .,/C $./ ..::'. ~. , ~ / >.9
<br />.ny, leadlnglothec.u.ellsled ~6'ltE"TO, OR ASACONSEOUENCE OF:
<br />On line ,.
<br />Eoterthe UNDERLYING CAUSE
<br />(dl.....or Injury IhellnlUated (c)
<br />theeventl resulting In death) . DUE TO, OR AS A CONSEQUENCE-OF:
<br />lASr
<br />
<br />Onset to death
<br />
<br />I
<br />- I
<br />I onsatto d.ath
<br />
<br />_ (d!.:-.-9-c;.?4~-, .,4..,,1'/.. ~".,. e ~,;-~..;.,.(...i.....-
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditlons cootributlng to the d.ath but ,,'ot re$ulting i 'e underlying ceu.e given in PART I.
<br />~;"A.../
<br />
<br />" ~"""., "x;:;
<br />
<br />
<br />sip 'fall with hip fx.
<br />e
<br />20.IF FEMALE: 21~~NNEROFDEATH 21b.IFTRANSPORTATION INJURY
<br />\;)A:IOI pregnant within past year I' Natural Q Homicide 0 Driver/Operator
<br />
<br />Jtl' Pregnant at time of death Q AccidentD Pending InvBstigaUon 0 Passenger
<br />o Not pregnant, but pregneot wilhin 42 day. of d..th 0 Suicide 0 Could nol be d.t.rmined 0 Pede.tri.n 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregn.nt, but pregnent 43 d.ys to 1 yee, b.lor. death 0 Othar (Sp,clfy) COMPLETE CAUSE OF DEATH?
<br />o Un~nown if pregnant within the past year Cl YES NO
<br />---;-~: DATE OF,I~URY (Mo" ,:aY'-V-;:;-L-TIME OF INJU"R:--- 220, PLACE OF INJURY-At home, larm, .tr..t, factory, offic. building, construction site, etc, ISp.cily
<br />
<br />
<br />22d, INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES 0 NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />o YES ~O
<br />
<br />Cl YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT.. NO,
<br />
<br />CITYiTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23C. TIME OF DEATH
<br />6:15 am
<br />
<br />z>
<br />~S~
<br />~~<<
<br />c.a:~~
<br />E ~IIJ t Z
<br />8ffi!i:O
<br />"z=>
<br />.Doo
<br />~:S~
<br />uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" D.y, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time. date and place and due to the cause(s) stated. (Signature and Title) T
<br />
<br />_. . . . .. 26."....' HAS ORGAN 0.. R TISS~. ATlON BEEN CONSIDERED?
<br />
<br />~ NO 0 PROBABLY U UNKNOWN 0 YES NO
<br />" ~27:-NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ITyp. or Prim)
<br />
<br />Jane McDonald M.D. 800 N. ALpha Ave., Grand Island,
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a I. NO "~:O
<br />
<br />NE 68803
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR IMo., Day, Yr,)
<br />
<br />MAY
<br />
<br />.4 2007
<br />
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