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STATE O~ NEBRASKA
<br />. ~ ` ~ ~ WMEN THIS GOPY CARRIES THE RAISED SEAL OF THE NEBRASKA MEALTH AND HUMAN SERVICES
<br />~ SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICM IS
<br />• THE LEGAL DEPOSITORY FOR VITAL RECORDS. /
<br />J_V/l IN
<br />PATE OF ISSUANCE
<br />TANLEY S. COOPER
<br />AUG ~ ~ ~Q~~ 2 4 0 9 0 5 4 9 0 ASSISTANT STATE•REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND WUMAN SERVICES
<br />STATE OF NEBRASKA-PEPARTMEN70F HEALTH AND HUMAN SERVICES FINANCE AND SUPPQR~ ~ n
<br />`, CER7IFICAI'E CF bEA7H (,, ]'S
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<br />_ ~ 1. pECEDENT'S•NAME (First, Middle, ~~ Last, ~ Suffix) 2. SEX 3. DATE OFDEA7H (Mo.,Day,Yr.)
<br />Jordan NMZ Wenz female Au ~ ~®~~
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br />Huntsville, Alabama 41 Aug. 9, 1965
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<br />7. SOCIAL SECURITY NUMBER 8e. PLACE OF DEATH
<br /> jj{J PS ITAL: ^ Inpatient Q~~ ^ Nursing Mome/LTC ^ Mospice Facility
<br />Bb. FACILITY•NAME pf not Inatltutlon, glue street end number)
<br />^ ERlOutpatient ^ Decedent's Home
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<br />St. Francis Skilled Care _ _.. _._ _ ~r~lea
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<br />8c. CITY OR TOWN OF DEATH pnglude Zlp Cgde) 8d. COUNTY OF DEATM
<br />Ba.gE51DENCE•STA7E eb.COUNTV Oc.CITYORTOWN
<br />Nebraska Ha11 Grand Island
<br />9d. 5TREETAND NUMBER 9e. APT. NO 9f. ZIP CODE gg. INSIDE CITY LIMITS
<br /> YES Q NO
<br />10a. MARITAL STATUS ATTIME OF DEATH ~Marrled ^ Never Married 106. NAME OF SPOUSE (First, Mlddle, Last, Sufflx) If wife, give maiden name.
<br />^ Married, but separated ^ Witlgwed ^ OlvgrCed ^ Unknown
<br />Randall L, Wenz
<br />11. FATHER'S-NAME (Flrat, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (First, Mlddle, Malden Surname)
<br />13. EVER IN U.3. ARMED FORCEST Olve dales of service II yea. 14a. INFORMAN7•NAME ~~~~~ lab, RELATIONSHIP Tp pECEDENT
<br />(Yes, no, Drunk.) np Randall L. Wenz husband
<br />75. METHOD OF DISPOSITION 16a. EMBALMER•SIONA7URE i5b. LICENSE N0. 15c. DATE (Mp., Dey, Vr. )
<br />^ Burial ^ Donetlon n Aug . 7, 2 0 0 7
<br />~I Cremation ^ Elnombment 18d. CEMETERY, CREMATORY OR OTHER LOGATION CITY /TOWN STATE
<br />^Removal ^Other(5peclfy) Central Nebraska Cremation, Gi.bban, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, C)ty CrTown, State) i Tb. ZIp Code
<br />All Faiths Funeral Hame 2929 S. Locust Grand Island NE 68801
<br />18. PART I. Enter the chain of evente••dlseaeea, Injuries, or compllcallona••that directly caused the death. p0 NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br />rasplratory arrest, or ventricular librlllatign without showing the etiglCgy. bC M107 ABBREVIATE. Enter omy qna cause qn a line. Add edaltionel Ilnas if nrcessary. I
<br />IMMEDIATE CAUSE: I onset to death
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<br />18. PART IL OTHER SIGNIFICANT CONDITIONS•Condltlona contrlbuting tc the death Cut not reaulting in the underlying cause given In PART I. 18. WAS MEDICAL EXAMINER
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<br />uvK ,C / ~ / OR CORONERCONTACTED7
<br /> ^ YES j~NO
<br />20.IFFEMALE: 21 e. MANNER OF DEATH 21 b. IFTRANSPORTA710NINJURY 27C.WASANAUTOPSVPERFORMEDT
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<br />p NOt pregnant wlthln pall year ~Neturel ^ Homlclde ^ Driver/Operator
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<br />~ ^Passengar ^ YES ~NO
<br />~: ^ Pregnant at time of death ^ Accidant^ Pending Investigation
<br />~~ ^ Not pregnant, but pregnant within 42 days of death
<br />^ Sulclde ^ Could ncl be determined ^ Pedeetrlen 21d. WERE AUTOPSY FINpINGS AVAILABLE Tp
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<br />'" ^ Not pregnant, but pragnan143 days to 1 year before death ^ Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />^ Unknown If pregnant wlthln the past year Q YES ~ NO
<br />22a. pATE OF INJURY (Mo„ pay, Yr.) 22b. TIME pF INJURY 22c. PLAGE OF INJURY•At home, farm, street, factory, office building, Construction alts, etc. (Specify)
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<br />22d.INJURYAT WORKT 22e. DESCRIBE WOW INJURY OCCURRED
<br />[] YES ^ NO
<br />221. LOCATION OF INJURY • STREET 6 NUMBER, APT. NO. CITY/TOWN STATE ZIP COPE
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<br />~:: 3 23a. DATE DF DEATH (Mo., Day, Yr.) ~ 24a. DATE 31GNEp (MO., Dey, Yr.) 24b.TIME OF DEATW
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<br />~ 23C.TIME OF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD Mo., De Yr. 24d.TIME PRONOUNCED DEAD
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<br />' ~' ~ 23d. To the best of my knowledge, death occurred al the time, tlate antl place ~) ~ O 24e. On the basis of exeminatlon and/or Investlgatlon, In my oplnlon death occurred at
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<br />- ~ 25.OIDTOBA000 USE CONTRIBUTETOTHE OEATH7 26a. HAS OH(3AN OR TISSUE pONATION BEEN CONSIDEREDT 28b. WA5 CONSENT GRANTEDT
<br />. ~~ ^ YES - ,P~NOy ^ PROBABLY ^ UNKNOWN
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<br />~~~ ^ YES ~' NO Not Applicable II 26a is NO ^ YES NO
<br />~ 27. NAME, TITLE AND ADDRESSDFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypearPrint)
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<br />.. Richard M. Fruehlin MD 2116 W. Faidle Ave. Grand Island NE 68803
<br />28a. REGISTRAR'S5IGNATURE 286. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />,~ ,~, AUG $ 200'
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