|
<br />~
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND:JJflMAN,SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN~~;ijiNffI;,- WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA71!1'}~Sc(ITfM,'~~flIS
<br />
<br />::~:::~::'ffORY FOR VITAL RECORDS. . .~~i61.
<br />JAN 1 0 2007 ASlSlSTANT.STATE! MGiStIiAIJ,
<br />LINCOLN, NEBRASKA 20 0 90 3 .t 0 7 HEA~r:H iN6-HuMMi-$ERl{igES
<br />-=~-~j:~_~._~=_.~', _~;~~i=-
<br />
<br />" "" ::".:::-::,': :,~.~:=.,::,-:"- i
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAf\lOSlJ....RPO~6
<br />CERTIFICAT~ OF DEATH _._~_:. U
<br />
<br />Micjdle, - -- l.asl.--- Sultix) 2. SEX "-- -.':C", --:' "--'f OATE O'F DEATH (Mo" Day, Yr.)
<br />William WanitschkeMale December_30, 2006
<br />
<br />(Flrsl,
<br />Charles
<br />
<br />345Q~__
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Merna, Nebraska
<br />
<br />5a. AGE-Last Blrlhday 5b_ UNDER 1 YEAR
<br />(Yrs_) 82 ~s
<br />
<br />
<br />6a. PLACE OF DEATH
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr,)
<br />
<br />June 24, 1924
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-32-0730
<br />
<br />/JQSflIAJ.:
<br />
<br />il Inpatlanl
<br />
<br />QII:JEB; D NuralnQ Home/LTC D Hospice Facility
<br />
<br />FACILITY.NAME (If not Instllutlon, give sltaal and numbar)
<br />
<br />D ER/Outpatlanl
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />D 1))\ D Othar (Spacily)
<br />
<br />J::OF DEATH
<br />Hall
<br />
<br />eo. CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />Grand Island
<br />
<br />9a, RESIDENCE.STATE
<br />Nebraska
<br />9<1. STREET AND NUMBER
<br />
<br />3317 Schroeder Ave.
<br />
<br />
<br />100, MARITAL STATUS AT TIMe OF DEATH QI Marrlad D Navar Married
<br />
<br />91 ~'; ~0~~_19g;S~~: CITY~IM~:'
<br />
<br />10b. NAME OF SPOUSE (First, Mlddla, La.l, Sulllx) II wlla, give maiden name,
<br />
<br />L_ Irma Curlile
<br />
<br />11, FATHER'S.NAME (First, Mlddla, La.l,
<br />Joe Wanitschke
<br />
<br />13, EVERIN u,s. ARMED FO;CES? Give dale. oloervlo.II-y~J 14a.INFOR';lANT.NAME
<br />(Yes,no,orunk,) No Irma Wanitschke
<br />"'-.""--.....-- .--..,.", .~
<br />15, MeTHOD OF DISPOSITION 16a, EMBALMeR-SIGNATURe ~ 1 eb, LICENSE NO.
<br />~Burial DDonatlon ~ '.....t: ~ ' /'7.?r
<br />D Cremation D Entombm.nl 1 6d_ CEMETERY, CREMATO~R LOCATION ' CITY I TOWN
<br />
<br />SuHix)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Dorothy
<br />
<br />Middle, Malden Surname)
<br />Karnes
<br />
<br />114b:"RELATIONSHIP TO DeCeDENT
<br />
<br />h6~DAT~~:~ Day, Y..r:). '
<br />~!l..IT_~_L 2007
<br />STATE
<br />
<br />D Removal D Other (Spaclly)
<br />
<br />Cedarview Cemetery
<br />
<br />Doniphan. Nebraska
<br />
<br />--,.~"'- -,.
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Str..I, Clly orTown, Statal
<br />Apfel Funeral Home 1123 West Second, Grand Island, NE.
<br />
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />18. PART I. Enter Ihe ~haln~--diseasesr InJuries, or complleallons--Ihat dlreclly caused the death. DO NOT enter lermlnal even,s such as cardiae arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE, Entef only one cause on a line. Add addlllonalllnes II necessary.
<br />
<br />IMMEDIATE CAUSE (FInal
<br />dlleilM or condition relulllng
<br />Indeath)_
<br />
<br />Sequ.ntl.lly tI.1 e.ndlll.n., II (b)
<br />.ny, I..dlng I. I~e oau..II.lod DUE Td, OR AS A CONSEQUeNCE OF:
<br />on line 8.
<br />Enterth. UNDERLYING CAUSE
<br />(dl..... or InJu,y t~atlnlll'led (0)
<br />Ih. ov.nlo re.ultlng In d.at~) DUe TO, OR AS A CONSeQUENCE OF:
<br />LASr
<br />
<br />IMMEDIATE CAUSE:. _ L _~ "1\"
<br />(a) ',,^~\L,.\~\Q..X'iG
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />-C,~\io.v" \i)
<br />\}
<br />
<br />I
<br />I
<br />I
<br />
<br />~~Qk tD~
<br />
<br />onsel to death
<br />
<br />I V
<br />
<br />,.JJ-
<br />
<br />onset 10 death
<br />
<br />on.al to dealh
<br />
<br />onaet to death
<br />
<br />(ll)
<br />
<br />1 B_ PART II. OTHER SIGNIFICAN. T CONDITIONS.Cond"lon. cont:ibullng 10 Ih~ deal~ bul nol ,e.ulllng In I~e underlying oau.r QCn In PAr I,
<br />
<br />" T.s. cQ,Q/I--VC'.t_ lcLe.?,f-I- D-L4-!>.-~. 03~:..z.o (l-~.A > d~\:;
<br />~,i:f ~- '--'_, "_
<br />,.1ffi01: 20, IF FEMALE: 21a, MANNER OF DEATH 21 b.IF TRANSPORTATION INJURY 210, WAS AN AUTOPSY PeRFORMED?
<br />~imr;,:, 0 Not pregnant wllhtn pasl year Q Natural 0 HomIcide [J Driver/Operator
<br />~~ . if Q passengar
<br />l~ D Pragnanlal tlm. 01 dealh D AccldanlD Pending Inv..tigation
<br />. I 0 Pedestrian
<br />D Nol pr.gnant, but pregnanl wllhln 42 day. of d.ath D SUlold. U Could not be del.rmlned. 21d, WERE AUTOPSY FINDINGS AVAILABLETO
<br />I - - ~Otn.'(SpeOlfY)
<br />.," D l'Iot pregnant, bUI pregnanl4J daya 10 1 year belore dealh COMPLETE CAUSE OF DEATH?
<br />
<br />t:: 0 Unknownlfpregnanlwllhlnlhepsslyear 0 YES 0 NO
<br />
<br />;" " 22.:'DATE OF INJURY (Mo, Day, Yr) - 220, PLACE OF INJURY-At hom., form, .tr.et,'aoIOry, 011100 building, construotlon sila, .to, (Spaolly)
<br />(!"'1 It,:
<br />:~---~,.
<br />I; 22d.INJURY AT WORK?
<br />
<br />19, WAS MEDICAL EXAMINeR
<br />OR CORONER CONTACTED7
<br />DYES A.NO
<br />
<br />DYES
<br />
<br />~O
<br />
<br />
<br />DYES D NO
<br />
<br />
<br />m
<br />
<br />221, LOCATION OF INJURY. STReET & NUMBER, APT, NO.
<br />
<br />CITYIfOWN
<br />
<br />smE
<br />
<br />ZIP CODE
<br />
<br />23a_ DATE OF DEATH (Mo_, Day, Yr.)
<br />DECEMBER 30, 2006
<br />
<br />24a. DATE SIGNED (Mo., D.y, y,,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />2Jb, DATE SIGNED (Mo., Da~ Yr.)
<br />JANUARY 2, Z007
<br />
<br />230, TIME OF DEATH
<br />19:59 Pm
<br />
<br />~H
<br />-p,iila:
<br />t?i~
<br />c.Q,cc::;
<br />~ffi~~
<br />!~o
<br />,2a::tJ
<br />8l;
<br />
<br />m
<br />
<br />240, PRONOUNCED DEAD (Mo" Day, Yr,l 24d. TIMe PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred at the time, d81e and place
<br />and due to Ih. cause(s) stated, (Slgnalur. and Tille) ~ I J h
<br />
<br />.~-) ~. ~---=- V'-"'\.V
<br />
<br />24e. On the ba$l$ 01 examination and/or Investigation, In my opinion death occ:urred at
<br />Ihe time, dale and plaoe and dua to Ihe cau'e(s) statad. (Signatura and Title) "
<br />
<br />25, DID TOBACCO USE CONTRIBUTnOTHe DeATH? 26., HAS ORGAN OR TISSUE DONATION BeEN CONSIDEReD? 26b, WAS CONSENT GRANTED?
<br />
<br />DYES 'uINO .... D PROBABLY D UNKNOWN D Y~S ~ Nol Applicable If 26. is NO DYES LJ NO
<br />nNAME, TrTLDNti AmjRESS OF CERTiFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTOFlNEY) (Typ. or Print)
<br />William Landis M.D. 2444 W. Faidley Ave., Grand Island, NE 68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bti, DATE FILED BY REGISTRAR (Mo., Day, Y<.)
<br />
<br />JAN 8 200&
<br />
<br />HHS-6111/03 (55061)
<br />
|