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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 STATISTICS ~~ ,~/CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -K-?; ~~-=- -'~-~=- <br /> <br />DATE DF ISSUANCE ~-. ~,," <br /> <br /> <br />L1:C~N~N~.~~~ 200710741 H:t!ii~ <br />\2~;~"?E~- .-~~,"f~'i=: <br />.~ ~-=:... -::--:..=~'~. ~ .~:~:- <br />STATE OF NEBR. .A. SKA - OEPARTMENT OF.H. EALTH AND HUMAN SERVICES F~~t4~S-mT ?.7 8 8 3 <br />....... . CERTIF:ICATE OF DEATH _-==- .L _ <br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX $. DATE OF DEATH (Mo" Day, Yr.) <br />Eduard Julius Wicht Male July Hh- 20~~ <br /> <br />\ <br /> <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br /> <br />Wood River. Nebraska <br /> <br />Sa. AGE.Last Birthd.y <br />(Yrs.) <br />84 <br /> <br />5b. UNDER 1 YEAR <br />MOS. DAYS <br /> <br />5c. UNDER t DAY <br />HOURS MINS. <br /> <br />6. DATE OF BIRTH (Mo., P.y, Yr.) <br />September 22, 1922 <br /> <br />7. SOCIAL SECURITY NUMBER <br />507-24-1811 <br /> <br />B.. PLACE OF DEATH <br /> <br />~: <br /> <br />IlQ Inp.tient <br /> <br />Qll:lEll: D NurSing Home/LTC D Hospice Facility <br /> <br />8b. FACILITY.NAME (If not institution, give strMt .nd number) <br /> <br />Good Samaritan Hospital <br /> <br />o ERfOutp.tienl <br /> <br />o Decedent's Home <br /> <br />OOCl\ <br /> <br />o Other (Specify) <br /> <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br /> <br />Kear:~ey <br />9.. RESIDENCE.STATE <br />Nebraska <br /> <br />68847 <br />~IUN;all <br /> <br />8d. COUNTY OF DEATH <br />Buffalo <br /> <br />9c. CITY OR TOWN <br />Cairo <br /> <br />lOa. MARITAL STATUS ATTIME OF DEATH iXMarried 0 Never M.rrled <br /> <br /> <br />9t.ZIP CODE <br />68824 <br /> <br />9g. INSIDE CITY liMITS <br /> <br />:Kl YES 0 NO <br /> <br />9d. STREET AND NUMBER <br />205 S. Suez St. <br /> <br />tOb. NAME OF SPOUSE (First, Middle, Lest, Suflix) If wife, give m.iden n.me. <br /> <br />o Married, but sep.r.ted 0 Widowed 0 Divorced 0 Unknown <br /> <br />Anabel Hodgson <br /> <br />11. FATHER'S.NAME (First, <br />Friedrich <br /> <br />Middle. Last, Suffix) <br />Ferdinand Wicht <br /> <br />12. MOTHER'S.NAME (First, <br />Wilhelmina <br /> <br />Middle, <br />Henrietta <br /> <br />Maiden Surname) <br />Seier <br /> <br />13. EVER IN U.S. ARMED FORCES? Give d.tes of service it yes. 14e.INFORMANT.NAME <br />(Yes, no, or unk.) No <br />15. METHOD OF DISPOSITION <br /> <br />o Buri.1 <br /> <br /> <br />14b. RELATIONSHIP TO DECEDENT <br />Wife <br /> <br />16c. DATE (Mo" Day, Yr. ) <br /> <br />o Dona.tion <br /> <br />Jul <br /> <br />15, 2007 <br />STATE <br /> <br />IXCrem.tion I.J Entombment <br />o Removal 0 Other (Specify) <br /> <br />Westlawp Memorial Park Crematoty. <br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City arTown, St.te) <br />Apfel Funeral Home, 1123 West Second. <br /> <br />Grand Island, Nebraska <br /> <br />PART I. Enter the (;.h~in of event!l--diseases, injuries, or compllcatlons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br /> <br />IMMEDIATE CAUSE (Fin'l <br />dl...... or condition ...unlng <br />In doalh) <br /> <br />Sequentially list condition., if (b) <br />.ny,I..dtng to the cause listed ----ouETo, OR AS A CONSEQUENCE OF: <br />on linea. <br />Enterlhe UNDERLYING CAUSE <br />(dl..... or Injury that Initiated (e) <br />lheevents resultin9 In death) DUE TO, OR AS A CONSEQUENCE OF: <br />I.ASI" <br /> <br />(0) <br /> <br />~~~ <br /> <br />~~" J-~~ ' <br /> <br />onSet to death <br /> <br />DUE TO. R AS A CONSEQUENCE OF: <br /> <br />I onset to death <br /> <br />onset to de.th <br /> <br />onset to death <br /> <br />(d) <br /> <br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditions contributing 10 the death but not resulting in the underlying cause given in PART I. <br /> <br />19. WAS MEDICAL EXAMINER <br /> <br />OR CORONER CONTACTED? <br /> <br />DYES <br /> <br />o NO <br /> <br />20. IF FEMALE: <br />o Not pregnant within pesl year <br />o Pregn.nt at time ot de.th <br />o NOI pregnenl. but pregn.nt within 42 days of deeth <br />o Not pregn.nt, but pregnant 43 days 10 1 year before death <br />o Unknown if pregn.m within the past year <br /> <br />210. MANNER OF DEATH <br />o N.tur.1 D Homicide <br /> <br />21 b.IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED? <br />o Driver/Operator <br /> <br />o AccldentD Pending Inve.tigation <br />o Suicide 0 Could not be determined <br /> <br />o Passenger <br />o Pedestrian <br />o Other (Specify) <br /> <br />o YES II NO <br /> <br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO <br /> <br />COMPLETE CAUSE OF DEATH? <br />-O-YES" 1:lINo <br /> <br />22a. PATE OF INJURY (Mo., D.y, Yr.) <br /> <br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, f.rm, street, factory, offloe building, construction site, etc. (Specify) <br />m <br /> <br />221. LOCATION OF INJURY. STREET & NUMBER. APT NO. <br /> <br />CITY/TOWN <br /> <br />STATE <br /> <br />ZIP CODE <br /> <br />23e. DATE OF DEATH (Mo., Day, Yr.) <br />-3........\. .~,,-,.. 0'" <br />23b. DATE SIGNED (Mo., D.y, Yr.) <br />- OAf <br /> <br />24a. DATE SIGNED (Mo" Dey. Yr.) <br /> <br />24b. TIME OF DEATH <br /> <br />m <br /> <br />~U <br />ut. <br />~~nl <br />"wZ <br />1iz::l <br />00 <br />~a:O <br />815 <br /> <br />m <br /> <br />230. TIME OF DEATH <br />c.2.-5"7 <br /> <br />24C. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD <br />m <br /> <br />23d. To the beSl of my knowledge, de.th occurred .t the time, date and piece <br />and due to the c.use(s) stated. (Slgneture end Title) ,. <br /> <br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at <br />the time, date and plaoe and due 10 the caus.(s) st.ted. (Signature and Tille) ,. <br /> <br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br /> <br />26b. WAS CONSENT GRANTED? <br /> <br />DYES Q.NO 0 PROBABLY 0 UNKN WN 0 YES 1lJ. NO N~.t~AEpliceble if 26. Is NO U YES ill NO <br />n NAME: 'rriu AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN DFiC6UNTY ATTORJjEY) (Type or Print) <br />Adeleke. E. Badejo M.D. 3219 Central Ave~J03Kearney. NE 68847 <br /> <br />28.. REGISTRAR'S SIGNATURE <br /> <br /> <br />28b. DATE FILED BY REGISTRAR (Mo.. D.y, Yr.) <br /> <br />JUL 2 5 2007 <br />