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<br />"",..,~,::. ~ 1 ""-:",~~. t'
<br />
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<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF t;jJAt!'fiI"'~MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE N~~ IIJ)fH!9.fj!J!!t'T OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOf!.''f' F~V'!l~'r''lfGbo;.lD9~' < .
<br />
<br />. 'f5' \ . 'b""- 'If
<br />DATE OFISSUANCE . '~':~'''''. _. r:.:__"",d:.~~" c}. .}
<br />, ,..; STA~5 . ~R':'r,.. "
<br />!"~~L:' ;E;~KA 200808679 ',~;:~_~J';
<br />
<br />
<br />STATE OF NEBRAS~..:~~PARTMENT ~_H~.!-!~ AND HU~ls.~vicii.~'~ !,z)~--~~...\..~. ~"tf.~..... ".1--'~'.3' . 8
<br />l.Ot=.KTIFICATE UI- ut=.ATH . 'I r. II "uat.,:s'~...a-o
<br />1.DECEDENrB-NAMI! (Flm, Mlddl., Loo.!, SU""') 2,SI!X . I.. ~ \ " . '.. .... (Mo.,Day,Vr.)
<br />".1." \.,,-."11'''1'
<br />Male . '.',;"':,PJ'ay"1, 2008
<br />St. AGE.LooOlllrthd.y lb. UNDER 1 'aAR 5c. UNDER tDIo/~ c, .. DATE OF IIRTH (Mo. Day, Yr.)
<br />HOURS I MINI.
<br />
<br />I November 5,1938
<br />
<br />(y...)
<br />
<br />MOS. 1 DAYS
<br />
<br />69
<br />eo, PLACE OF DEATH
<br />I::IQIfII&.;. 0 Inpatlom JmWt 0 Nu..lng Homo/L TC
<br />
<br />_____ ._g--=-~lpa~~ __._ ___~~~r. Home
<br />o DCA 0 DlMr(Spoclfyl
<br />
<br />o Hooplce F.cAIly
<br />
<br />()
<br />''F\I
<br />k
<br />
<br />Oarrel G Rewerts
<br />
<br />". -..J
<br />
<br />rural Adams County, Nebraska
<br />7. SOCIAL SECUIVTY NUlllleR
<br />
<br />~
<br />~
<br />w
<br />lli-f328O"SoulhMonltor Road--- ..
<br />o
<br />...I
<br />~
<br />W
<br />Z
<br />~
<br />j
<br />i
<br />!E
<br />
<br />I
<br />a.
<br />S
<br />u
<br />~
<br />o
<br />I-
<br />
<br />50548~5285
<br />
<br />lb. FACILITY-NAIIIE (If nOllnolllutlon, glv. .1nOOI.nd nu""'."
<br />
<br />Ie. CITY OR TOWN OF DeATH (Includ. Zip Cod.)
<br />
<br />Ooniphan 68832
<br />
<br />III. RI!SlOENCE.sTATE /Ib. COUNTY lie. CITY OR TOWN
<br />
<br />Nebraska Hall I OOniphan
<br />
<br />ed, STREET AND NUIIIBI!R I g.. AFT. NO, I II. ZIP COOl!
<br />
<br />13280 South Monitor Road 68832
<br />
<br />lOa. MARITAl. STATUS AT TIME OF DEATH iii MoITI.d 0 Novo< lIIalTledl10b. NAIIIE OF SPOUSE IFlrot. Mlddl., Loo.1, Su"",) It wlf.. glv. mold.n no.....
<br />
<br />o Monted, bUI.",.raled 0 Widowed 0 Divorced 0 Unknown I Patricia Plsczek
<br />
<br />11. FATHER'S-NAMI! IFI..I, IIIlddl., Loo.1, Suffix) 112' MOTHI!R'S-NAME (F....I, IIIlddl., Mold.n sumo...)
<br />
<br />Francis Rewerts Elfrieda Paoenhagen
<br />13. EVER IN U.S. ARMED FORCES? GIY. d.lo. ol.....lco "y...114o.INFORIIIANT-NAIIIIE
<br />
<br />(Yn,No,orUnk,lr'es 11-?7-56 11-26-62 I Patricia Rewerts
<br />15. IIII!THOD OF DISPosiTION 11.. I!IIIBAl.IIIER.flIGNATURE
<br />0'"""' 000.1110.
<br />[II CffI....., Olnklmbmenl
<br />0-." OOIl"~I"",,,1
<br />
<br />18d. COUNTY OF DEATH
<br />Hall
<br />
<br />lUg. INSIDE CITY LIMITS
<br />o Yn iii No
<br />
<br />14b. REl.All0NSHIP TO DECEDI!NT
<br />
<br />Wife
<br />
<br />Not Embalmed
<br />
<br />/1Ib. I.ICENSE NO.
<br />
<br />11e. DATE (Mo. Day, Yr.)
<br />
<br />May 8, 2008
<br />
<br />lid. CEMI!TERY, CREMATORV OR OTHI!R I.OCAll0N
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />Nebraska
<br />I 17b. Zip Cod.
<br />I 68901
<br />
<br />, Central Nebraska Cremation Service
<br />
<br />170. FUNERAl. HOME NAMI! AND MAlI.ING ADDRESS (S....I, City or Town, Slalll)
<br />Brand-Wilson Funeral Home, 505 N Bellevue, Hastings, Nebraska
<br />
<br />Gibbon
<br />
<br />~"_.
<br />
<br />CAUSE OF DEATH (S.. Instructions and examples)
<br />_ ~'t-;~~,:;~~~~~:~.~':.:I~~~~.:~=::;:n~~-..dtht""'.-r~=-.i:.=-cn..~., _ ;. -- "--,- ~~'~_
<br />IIIIMEDlATE CAUSE:
<br />
<br />IMIIII!DIATE CAUSE (FI..I
<br />dl..... or condition rHultlng .,
<br />In d..lh)
<br />
<br />cardiac arrest
<br />
<br />.:A'!8IlQlIIIIMUa&Il__--~-
<br />! on.et to duth
<br />
<br />1 unknown
<br />i onoollo dulh
<br />
<br />!unknown
<br />; VIJ.&t to d..tn
<br />
<br />';,;. ~:.r""'!'"- ~.-
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />S...u.nllally llal condlllon., II b)
<br />.ny, ludlng Iolhoc.U..llahld hea rt d;s ease
<br />
<br />on IIn. .. [)I,)';: TO, OR AS A ::;~':~GEQlil!:N;:E Or-:
<br />
<br />I!nhlrlh.UNDERl.YlNGCAUSE c) high blood pressure
<br />(dl..... or Il\Iury Ihollnltlaled -
<br />th. ",.m. rUuIII", In d..IIl' DUE; TO, OR AS A CONSEQUI!NCE OF:
<br />I.AST
<br />
<br />d)
<br />11. PART II. OTHER SlQNIFICANT CONDlTlONS.condlllono contrlbullng 10 Ihe d..th bUI not...ultlng In th. und'rlylng cou.. glY.n In PART I.
<br />
<br />! 30 years
<br />!GnaOlIO death
<br />
<br /> ffi
<br /> Ii:
<br /> ffi
<br /> u
<br /> j
<br /> I
<br /> 8
<br /> .!
<br />-"
<br />-- ~
<br />
<br />1 g. WM MEDICAL EiXA/ollNER
<br />Oil CDRONI!R CONTACTED?
<br />KJ YES 0 NO
<br />
<br />20. IF FEMALE:
<br />o NO! prog..nt within put year
<br />o .....g..nl.l_ 01 duth '
<br />o Not prognam. bul prog"nl within 42 day. 01 d..th
<br />o NOI _nom. bul prognonl43 d.y. 10 1 y..r bero.- d..g,
<br />OUnknown "",",..nt within th. p..1 yoar
<br />
<br />21.. MANNI!R OF DEATH
<br />[]CNoIU,:,,1 0 HomlCld.
<br />o Accldanl . 0 "-ndlng Inveollg.~on
<br />o SUlcld. 0 Could 1101 b. d.ionnlnod
<br />
<br />21b.IF TRAHSPORlATlON INJUR'l
<br />o Dltvor/OP"",lor
<br />o P....ng.r
<br />o Pod_trlan
<br />o OIhor (Specify'
<br />
<br />21c. WAS AN ,AUTOPSY PERFORMEP?
<br />o YES ~ NO
<br />
<br />z:id.WERE AUTOPSY FINDINGS AVAlLABI.E
<br />TOCOMPl.liTI!! CAUSE OF DEATH?
<br />DYES I2!INO
<br />
<br />220. DATI! OF INJURV (Mo., D.y, Yr,) I ~b. TIME OF INJURY I ~c. PI.ACE OF INJURY-AI homo, farm. alrool, factory, oIIIco building. con.truC~IIIIIo. .Ie. (Speclly)
<br />
<br />
<br />22d.INJUIlY~!_WO~~?J.~q~V __ _
<br />DYI!$DNO 1
<br />
<br />,t,~", ~~.' ' ,,JF.,i;::,.':=-=~~~"'" '-
<br />
<br />~f. I.DCATlON OF INJURY - STIlEI!!T & NUIIIBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATI!
<br />
<br />ZIP CODE
<br />
<br />2310. DATE OF DEATH (Mo" Day. Yr.)
<br />
<br />240. DATE SIGNED (Mo" Day, Vr.)
<br />!'Ii May 22, 2008
<br />I ~ 0 24c. PRONOUNCED DEAD (Mo" Day, Yr.) 244. TIME' PRONOUNCED DEAD
<br />
<br />~ S i I MtI V 7 ?nnA A d1A tI m
<br />. . ~ ~ 2....0.11 !be ...... 01 _nII""~on .ndlor 11I'I""I1OUOn,ln mY oplnlein dillllh' occu...d
<br />. . g ~ g .i.~..- ....nd ploc..nd du.1o th. clu..(I'.llIlOd.(SlgnalU...nd Till.'
<br />
<br />~ 8 ~ &-.) __ Hall County Attor ey
<br />
<br />34b. liME OF DI!ATH
<br />
<br />!'~
<br />I~~
<br />Sf!
<br />\ ~i
<br />
<br />8:20
<br />
<br />am
<br />
<br />23b. DATI! S1QNED (1110., Day, Yr,) /23C' TIME OF DEATH m
<br />
<br />
<br />23c1. Tolho ....1 01 my knowloclg., d..lh occurred .1 tho limo, d.1o .nd ploc.
<br />and duo 10 tho CIIu..(.)'IlIIod, (SlgnolU.. and Till.)
<br />, :JIC ..
<br />
<br />~
<br />r---
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THI! DEATH? 12811. HAS ORGAN OR,TISSUE DONATION BEEN ~ED?
<br />o VES Il.NO 0 PROBABI.Y 0 UNKNOWN 0 YES ll: NO
<br />
<br />27, NAIIIE. TITLE AND ADDRI!SS Of- CERTIFIER (PHY&ICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Mark J. Young, Hall County Attorn}y, 231 ~. ~ust St., Grand
<br />
<br />2... REGISTRAR'S SIGNATURE ,,..,.,, A {MIa .
<br />r,'Y '0'" N' n..~..-
<br />
<br />121b. WMCONSENl:GAANTED?
<br />Not Appllcabla 1121111. Np. 0 YESJQ NO
<br />
<br />-~,:'
<br />
<br />Island, NE 68801
<br />
<br />p
<br />
<br />21b. PATE FII.ED BY IIEGoSTRAR (Mo" Doy, Yr.)
<br />
<br />MAY J 9 200S
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