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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTI#AND ~$,
<br />SYSTEM, IT CERTJRES THE BELOW TO BE A TRUE COpy OF THE OR,!,INAL ~..i~" ,;'i:'
<br />
<br />:TE=~~~=~~'SYS~ VlTALBt~Y~';i
<br />JAN 8 2003 200902689~~~~..
<br />AS~~ST4T1.1JE(jI$TJWf/i!
<br />. LINCOLN, NEBRASKA_ HEALTH AN8HtJ(fA1C~1I!W:
<br />,.',:' .;"i,~~, '~~7-:,';'~:'~,~'~:',~~"'~, ~'_.', 'jff- , ~
<br />STAlE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMAN'SERVlCEs'fiIiiANeE ~RT
<br />VITAL STATISTICS '. -"'-~\' \~~~#..-
<br />CERTIFICATE OF DEA rn3'O 0 0
<br />~,~., 'DATE OF ~TH (Month. Day. Year!
<br />
<br />,'Janua
<br />
<br />6
<br />
<br />, DECEDENT. NAME
<br />
<br />
<br />FIRST
<br />
<br />LAST
<br />
<br />2 SEX
<br />
<br />MIDDLE
<br />
<br />Ila
<br />
<br />J.
<br />
<br />Walz
<br />
<br />4. . CITY AND STATE OF BIRTH /II fICI in V$.A.. 1IlI~ e_try)
<br />
<br />5.. AGE. Last Bir1lld.V
<br />IY"'.I 72
<br />
<br />UNDER 1 YEAR
<br />Sb MOS I DAYS
<br />I
<br />
<br />1930
<br />
<br />Rosem:mt,' Nebraska
<br />7, SOCIAL SECURTlY NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />tlQ!lPIT AL: ~ Inpatien'
<br />
<br />o ER OUtpatient
<br />
<br />o DOA
<br />
<br />OTHE~. D Nursing Home
<br /> D Residence
<br /> 0 Other {Spec/till
<br />
<br />81>.
<br />
<br />
<br />(ff not IfJstiluti(In. give stteef .!nd numbsr)
<br />
<br />.Byran LGH Medical Center East
<br />11.<:, CITY TOWN QR LOC~.II.QN OF DEATH
<br />
<br />Lincoln
<br />ta. RESfllENCE"'ST A TE
<br />
<br />
<br />8d INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />
<br />
<br />9d. STREET AND NUMBER /lnc/Wing Z;p Code)
<br />
<br />90. INSIDE CITY LIMITS
<br />Yes Q No D
<br />
<br />Nebraska
<br />
<br />6880
<br />
<br />10. RACE -Ie.g, White. BI.ek. Ame"e.n Indi.n. 1,. ANCESTRY le.g..ItaUan.I.lt,.,an. Gorman, .'cl
<br />
<br />....IISpoelfyl (Spoc'fyl
<br />Wl11te Gennan
<br />
<br />.... USUAL OCCUPATION {Give kind oI_k <1CIIlI1Iurlng most
<br />of working liftJ. (lVM1 jf te/ifedl
<br />
<br />Homemaker
<br />
<br />16. FATHER - NAME
<br />
<br />17 MOTHER
<br />
<br />.15. EDUCATION ISpoc'fy onlv .'ghost grodo complotodl
<br />Elomen"l'2Seoonclary 10.121 College /1.40' 5-1
<br />
<br />MIDDLE MAIDEN S RNAME
<br />
<br />.,.
<br />
<br />Domestic
<br />lAST
<br />
<br />FIRST
<br />
<br />
<br />SWeeten
<br />
<br />MIDDL~
<br />
<br />John
<br />
<br />Stella
<br />
<br />16. WAS DECEASED EVER IN U.S. ARM~D FORCES?
<br />{Yes, no, or l,lnk.1 ftf ve5. give war' aM clales 01 servicesl
<br />No
<br />
<br />19b. INFORMANT
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. ST A T~. ZIPI
<br />
<br />MAILING ADDRESS
<br />
<br />
<br />Grand Island, Nebraska 68803
<br />21.. METHOOOFOISPOStTlON 21b. DATE
<br />
<br />21C. C~METERY OR CREMATORY NAME
<br />
<br />1287
<br />
<br />~ Bu,ial 0 Remo,.1 1-4- 2003 Grand Island Ci t
<br />21d CE...ETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />C)
<br />N
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<br />C)
<br />CD
<br />o
<br />N
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<br />c:
<br />:!:
<br />m
<br />~
<br />2:
<br />o
<br />
<br />o Cremation 0 Don...",
<br />
<br />3168 W. Stolle Park Rd. Grand Island Ne
<br />
<br />
<br />Curran Funeral. Cha 1
<br />lItb. UNERAI. HOME ADDRESS' lSTREET OR ll.F.D. ND..GlTY OR TOWN. STATE, ZlPI
<br />
<br />3005 So. Locust Grand Island, Nebraska 6~801
<br />23. I...MEDlATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal.lbl. AND 1<11
<br />PART
<br />11.1 ( Pneumonia
<br />DUE TO, OR AS A CONSEOVENCE OF
<br />
<br />Interval betwee" onset and death
<br />
<br />Interv$1 between onset and death
<br />
<br />Ibl KSevere Pulmonary Hxpertension
<br />OUE TO. OR AS A CONSEOIJENCE OF,
<br />
<br />1 year
<br />Interval berween onset and deafl'l
<br />
<br />Interstitial Lun
<br />
<br />Disease
<br />
<br />:&.
<br />
<br />
<br />lei
<br />OTHER SIGNIFICANT CONDITIONS. Conditions contributing to Ine ~ath but not related
<br />P~,RT of
<br />
<br />:!6b, DATE OF INJURY {Mo.. o.y. Yr.} 26<;. HOUR OF INJURY
<br />
<br />o Accident 0 Undetermined
<br />o Suicide 0 Pending
<br />o HomiCide Inve5tigation
<br />
<br />
<br />
<br />:!Go. INJURY AT WORK
<br />Ve. 0 No 0
<br />
<br />27.. DATE OF DEATH {Mo.. Day. Yt.}
<br />
<br />;>lie DATE SIGNED {Mo.. Dav. YO
<br />
<br />:!ell. TIME OF DEATH
<br />
<br />
<br />$~
<br />!l ~
<br />Bf
<br />~~
<br />
<br />$~i
<br />I ~ ~ ~ 26c PRONOUNCED DEAD (Mo o.y. YtI
<br />
<br />
<br />
<br />~ i g 28e On Ihe baSIS of examinatIon aM Of Invesllgallon. III my oplnaon dealo occurred at
<br />o ~ the time, date and piece and due to tne cause(s.) statMl.
<br />
<br />28d PRONOUNCED DEAD (/IoU1I
<br />
<br />3O.b. WAS CONSENT GRANTED'
<br />o YES ~O
<br />
<br />Johl) F. Trapp M.D. 1500 South 48 St.
<br />320. REGISTRAR
<br />
<br />Nebraska 68506
<br />32b. DATE FILED BY REGISTRAR {Mo.. Day. Yt.}
<br />
<br />JAN 7 2003
<br />
<br />I
<br />
<br />M
<br />
<br />M
<br />
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