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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 SECTION,WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. M....._..~,.. ',f)..;';"",<'2" II~~.""'. .~..
<br />
<br />DATE OF ISSUANCE JJ,~,:tt:;'':E1(.'i PPC!1PER
<br />
<br />AUG 1 0 2007 :is~~," tA~tf~TMR
<br />200902835 t1EAtFH~IrJMAJqEf1~ES
<br />:~' :.w; S' ~~"~." tl. 'L~'" ..' :. "':I .
<br />,( ?...- . . '.' r<. If"~ \ :.
<br />J, C', : ". .' ':-'4~' : _'
<br />STATE OF NEB. RASKA - DEPARTMENT OF HEALTH AND HUMAN SEFlV~~fINAN<;;e:.p,l'ipsUpp." ~A~ . 2 () A 9 ?
<br />'~--~., CERTIFICATE OF DEATH"', .....;,.,. ' ,,'1'. U L _ 0 ~ __
<br />1. DECEDENT'S.NAME (First, Middle, Last, Sutlix) '2.'5EJ(";.:....:.. 3, DATE OF DEATH (Mo" Day, Yr,)
<br />Jordan NMI Wenz "f'emale A~. 5, 2El01
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa, AGE.Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo" Day, Yr,)
<br />(Yrs,) MOS, DAYS HOURS MINS,
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />Alabama
<br />
<br />41
<br />
<br />Aug. 9, 1965
<br />
<br />6a, PLACE OF DEATH
<br />llillll'il8l.;
<br />
<br />a lopationt
<br />
<br />QlliE8; Q Nursing Home/LTC a Hospice Facility
<br />
<br />a ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />Francis Skilled Care
<br />
<br />a[D4.
<br />
<br />~killed
<br />:lCI Other (Speclty) .<I r p
<br />
<br />Be, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />9a, RESIDENCE,STATE
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />...AYe.~._
<br />1 Oe, MARITAL STATUS ATTIME OF DEATH 5l;Married a Nover Married lOb, NAME OF SPOUSE (Firat, Middle, Last, Suffix) It wife, glva maiden namo,
<br />
<br />a Married, but seperated a Widowod a Divorced CI Unknown
<br />
<br />Randall L. Wenz
<br />
<br />11, FATHER'S-NAME (First,
<br />
<br />Middle,
<br />
<br />Laat,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (First,
<br />
<br />MiddlO,
<br />
<br />Meiden Surname)
<br />
<br />a Burial
<br />
<br />CI Donetion
<br />
<br />14a.INFORMANT.NAME
<br />
<br />Randall L. Wenz
<br />16a. EMBALMER.SIGNATURE 16b, LICENSE NO,
<br />
<br />
<br />XI Cremation CI Entombmant
<br />CI Removal CI Other (Spacify)
<br />
<br />n t embalrn.ed.._
<br />16d, CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />husband
<br />16c, DATE (Mo., Dey, Yr.)
<br />Aug. 7, 2007
<br />
<br />(Yes, no, or unk.) no
<br />15, METHOD OF DISPOSITION
<br />
<br />STATE
<br />
<br />Central Nebraska Cremation, Gibbon, Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Straet, City or Town, Statal
<br />All Faiths Funeral Home 2929.S.
<br />
<br />18. PART I. Enter the chain of eventlt--diseases, injuries, Or c;:ompllcationsnthat directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />rasplretory arresl, Or vantrlcular tibrlllatlon without showing the etiology, DO NOT ABBREVIATE, Entar only one cause on a line. Add additionalllnas if necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl...... Or COndKlon ,""uKlng
<br />IndMlll)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />:~ET~~~A~~~QUE:~:cep~JOfA~
<br />(b) c1Cvt*- V-e~th'CtdCU RlanIJJl~CM/CtR4rf/DCtfI'1t'fT
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c) r{l)SS,'bJe fDlMt'Jt'41 Ca.,JI'O",#Of2~!ut/
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />5 "::>
<br />
<br />onset to death
<br />
<br />Sequentially list conditions, II
<br />any, leading to the causeUsted
<br />on IIn..,
<br />Entertho UNDERLYING CAUSE
<br />(dl..... or Injury thet Inltieted
<br />the a""nw resuKlng In deeth)
<br />LASr
<br />
<br />SfJ.HIJ/Ls.
<br />
<br />onset to death
<br />
<br />onset to desth
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS. Conditions contributing to the daath but not resulllng in the undarlylng cause given in PART I.
<br />
<br />Qcu Vt RelAid FO,lll.!t-~
<br />
<br />CI AccidenlCl Pandlng Invastlgation
<br />CI Suicida CI Could not be determined
<br />
<br />21b, IFTRANSPDRTATION INJURY
<br />CI Driver/Operator
<br />
<br />a Passanger
<br />
<br />(J Padestrlan
<br />
<br />CI Olhar (Specify)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />CI YES NO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />lzt Not pregnanf within past year
<br />CI Pregnant at time of deeth
<br />CI Not pregnanl, but pregnant within 42 days of death
<br />a Not pregnant, but pregnant 43 days to 1 year botore death
<br />CI Unknown if pragnant within the past year
<br />
<br />21a, MANNER DF DEATH
<br />R{Natural a Homicide
<br />
<br />CI YES Ji('NO
<br />
<br />2,2~._TI",E.oF ~...lII!Y-- ~&-oF INJURY.Athome, farm, street,factory; ottica building, construction slle, etc, (Specify)
<br />m
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />. (J YE$. _ ~,N.Q.
<br />
<br />CI YES CI NO
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CfTYlTOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />'~''--------oo-~'_
<br />
<br />23a, DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />am
<br />
<br />...~~
<br />.alii if
<br />If5>
<br />~~~~
<br />B~5
<br />.e.~ ~
<br />
<br />m
<br />
<br />---.August
<br />23b, DATE SIGNED )Mo" Day, Yr,)
<br />aU uSr &J) :J.OCJ7
<br />
<br />23d, To the bast of my knowledge, death occurrad at tha time, data and place
<br />and due to the ceu..(s) stated, (Signatura and Title),.
<br />
<br />
<br />23c, TIME OF DEATH
<br />10:52
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />i4tD
<br />
<br />24e. On the basis 01 examination and/or investigation, in my opinion death occurred at
<br />the time, date and placa and due to the causers) stated, (Signature and Title)"
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicable If 26a is NO CI YES NO
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />Grand Island
<br />
<br />NE 68803
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />AUG 8 2001
<br />
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