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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL THIJJ:ii/'Hti.~ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA$,.... lIEcJ.F<;l:!/i.ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR v.iT;' .,,'4,.".
<br />. ......." '.':~<. ':<.~;;"~'~':~',,j ,
<br />
<br />
<br />
<br />200900248
<br />
<br />DA TE OF ISSUANCE
<br />
<br />DEe 31 2008
<br />
<br />1. DECEDENTS-NAME (First,
<br />
<br />Alfred Hen
<br />
<br />Petzoldt
<br />
<br />Male
<br />
<br />.. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Ga. AliE-Lul Birthday lib. UNDER 1 YEAR lie. UNDER 1 DAY I. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />(Yrs.)
<br />
<br />MOS. DAYS
<br />
<br />HOURS MINS.
<br />
<br />St. Libory, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />lb. FACIUTY-NAME (If nollnatltuUon, glva .traat.nd numb.r)
<br />
<br />93
<br />
<br />Sa. PLACE OF DEATH
<br />
<br />twaelIAl.;. D.lnpallanl
<br />
<br />o ERIOulpaUanl
<br />
<br />ODOA
<br />
<br />February 12,1915
<br />
<br />508-30-2742
<br />
<br />l:IIIlEB; IXI Nursing Homa/L TC
<br />o Dac_nr. Homo
<br />o OtharjSpaclly)
<br />
<br />o Hoaplca Facility
<br />
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />Grand Island 68803
<br />go. RESlDENCE-STATE
<br />
<br />Id. COUNTY OF DEATH
<br />
<br />Nebraska
<br />
<br />Id. STREET AND NUMBER
<br />
<br />4002 Mason Avenue
<br />
<br />Hall
<br />
<br />
<br />81. ZiP CODE
<br />68803
<br />
<br />Bg. INSIDE CITY LIMITS
<br />11!1 Yaa 0 No
<br />
<br />w
<br />Z
<br />:::J
<br />II..
<br />~
<br />il
<br />II:
<br />
<br />I
<br />
<br />'a.
<br />E
<br />8
<br />.!
<br />o
<br />I-
<br />
<br />Db. COUNTY
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH Iii!Marrtad 0 Navar Marrtad 10b. NAME OF SPOUSE (First, Mlddl., L..t, SlllIIx)lfwtf., glv. mold... n.ma.
<br />o Marrtad, bulaapor.lId 0 Wldow.d 0 Dlvorcad 0 Un""own
<br />
<br />Ernest
<br />
<br />Petzoldt
<br />
<br />
<br />,a ",..9
<br />
<br />lIb. LICENSE NO.
<br />/-$97
<br />
<br />11. FATHER'S-NAME (First,
<br />
<br />Mlddl.,
<br />
<br />L..t,
<br />
<br />SlllIIx)
<br />
<br />12. MOTHER'S-NAME (First, Mlddl.,
<br />Wilhelmina Sto kotte
<br />
<br />M.ldan Sum.ma)
<br />
<br />(y.., No, or Unk.) Yes
<br />1&. METHOD OF DISPOSITION
<br />iii.....' ODo_n
<br />Oc_n O~.....nt
<br />O...mo.., Oot...~.pO<Ify,
<br />
<br />CITYfTOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Souse
<br />
<br />ll1e. DATE (Mo.. D.y. Yr.)
<br />
<br />December 30,2008
<br />
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glva datea ora.rvlc.lf Y.L
<br />
<br />Grand Island Cemetery
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Stre.l. City or Town, Stel.)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Cod.
<br />68801
<br />
<br />CAUSE OF DEATH See instructions and exam les
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition _ulllng
<br />In d..th)
<br />
<br />1.. PART I. Em.r the chain 8/---. . d........ Inju...... or c:ompltc:attons- tna. dll'Ktly cal.lIH ..... death. DO NOT....... tttrnllUll rHlnta euch l1li. cerditlc ........
<br />....plratory arrest. or ftnUtcullr flbnl..uon WIthout enowlng tne etiOlogy. DO Nol ABllevtATI!. I!m.r only OM eail.. 01'1 a riP., Ad~ addlUo...1 U.... If ""~"Uy.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />.) <~
<br />
<br />DUE TO, OR AS A ~ONSEQUENCE OF:
<br />b) XS~-'\A.tL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />I APPROXlMATI! INTERVAL
<br />,
<br />I on..llo d.llh
<br />I
<br />I
<br />: I c)
<br />
<br />
<br />Sequentl.lly II.t condlUon., If
<br />any, le.lny to the c.u.. U.ted
<br />on Un. ..
<br />
<br />: onolllo da.lh
<br />I
<br />: I \
<br />
<br />En,"r tho UNDERLYING CAUSE c)
<br />(dl..... or Injury lhIllnlU.lad
<br />tho .v.nls ...uIUng In d.ath) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />: on..t to death
<br />I
<br />I
<br />I
<br />I
<br />
<br />d)
<br />
<br />, on..110 d..lh
<br />I
<br />I
<br />I
<br />I
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTIONS-Condl on. contributing 10 th. d..th but no! ...uIUng In th. undoo1ylng oau.. glv.n In PART I.
<br />
<br />
<br />210. MANNER OF DEATH
<br />'N.lur.1 0 Homlcld.
<br />o Aceld.nl 0 Pandlng _Ull.Uon
<br />o Sulcld. 0 Could nol bo dOlennlnad
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />o Drlv.rlOpar.lo,
<br />o P....ng.'
<br />o P.d..trian
<br />o Olh.r (Spaclfy)
<br />
<br />1'. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~' NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />o YES NO
<br />
<br />II::
<br />W
<br />i
<br />j
<br />i
<br />Ii
<br />~
<br />u
<br />.!
<br />{2
<br />
<br />20. IF FEMALE:
<br />o Nol prsgn.nl wtthln po.1 y.ar
<br />o Prognanl .1 limo or d..th
<br />o Nol prsgnant, but prsgnanl within 42 d.y. of daalh
<br />o Not p...un.nt, but pngnant 43 day. to 1 y.ar Hfo... de.th
<br />OUnknown If progn.nl wtthln th. pUI YO.'
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLl!TI! CAUSE OF DEATH?
<br />DYES ONO
<br />
<br />220. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />
<br />22b, TIME OF INJURY 22c. PLACE OF INJURY-AI homo, f.rm, .troIl, fOClorv, otllc. building, conalrucUon sll., .Ic. (Spoolly)
<br />
<br />nd. INJURY AT WORK?
<br />DYES ONO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />240. DATE SIGNED (Mo., D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />8: 05 am
<br />
<br />>o~~
<br />~U~
<br />J;~>
<br />",lLo( 2
<br />g!'li!: 0
<br />uWl
<br />! oiS
<br />oa:u
<br />I-lh
<br />
<br />m
<br />
<br />z
<br />~~
<br />J~>
<br />"'lL..J
<br />E ",Z
<br />8c:O
<br />!~
<br />.2~
<br />
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />23d. To th. bul 0' my knowl.dgo, da.th OCCUrrad .Ith. Umo, d.te .nd plac.
<br />and du.lo th. c.uso(.) steled. (Slgnalurs _TIU.)
<br />
<br />WJ~
<br />
<br />m
<br />
<br />240. On tho bul. or.""mlnlllon and/or InvnUlllllon, In my opinion da.lh occurrod
<br />11th. Umo, date _ plac. and du.lo th. eauoo(.) .1Ilod. (Slgnalu.. .nd Till.)
<br />
<br />
<br />281. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 'NO
<br />
<br />Db. WAS CONSENT GRANTED?
<br />Nol Appllclbl.1f 28.1. NO 0 YES ~ NO
<br />
<br />2? NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo Or Prlnl)
<br />
<br />willi
<br />
<br />~I
<br />
<br />
<br />DEe 3 1 2008
<br />
<br />
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