<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 />
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