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STATE ~E NEBRASKA
<br />_ - WMEN TWIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CER'~IFHES TF"IE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIGS SECTION, WHICH IS
<br />• ~ ~ THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />~~~-+
<br />DATE OF ISSUANCE (~ C A (~ /~'
<br />~UC7 ~• ~ ~a~~ ~ O O 9 O 5 `~ 9 ~ rANLEYS. COOPER,
<br />ASSISTANT STATE~REGISTRAR;~. RE-RECgRpED
<br />LINCOLN, NEBRASKA HEALTH AND WUMAN SERVICES~~,
<br />2oo9oso75
<br />57ATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPQRy,,, ~ Q n Q
<br />~ f'~RTI<`If'_ATF r1C 11CAT41 (ll lJ
<br />
<br />_°.___.
<br />~' 1. pEGEDENT'S-NAME (First, Middle, Last, Suffix) _ __
<br />2. SEX _. LJ.~ L V...Z . ~ r ~.
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />„h~.' Jordan _,_ ...NMI Wenz
<br />'.I:: female: Au ._ 5_, 2p(~~'
<br />_
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FDREIGN COUNTRY OF BIRTH
<br />~
<br />5a. AGE-Lest Birthday
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY _
<br />8. DATE OF SIRTH (Mo., Dey, Yr.)
<br />' (Yrs.) MpS. DAYS HOURS MIN$.
<br />Huntsville, Alabama 41 Aug. 9, 1965
<br />7. SOCIAL SECURITY NUMBER 8a. PLAGE OF DEATH
<br />• C~a_ HOSPITAL: ^ Inpatient Q Nursing Home/LTC ^ Hospice Facility
<br />Bb. FACILITY•NAME (II not institution, give street end number)
<br />...... .. -_....._.. _ -._.-. ~_
<br />.. _ ..__.
<br />- .._.__ ....~-EAlOutpaUont- -----.... ...~--Bseadsnt'cKam~ --.._........
<br />
<br />St. Franc~,s Skilled Care _.- .---- ._.._..._ kzl-led. .
<br />^ Da+ ~ClOther(spadily)
<br />Sc. CITY OR TOWN OF pEATH (Include ZIp Code)
<br />~ 8d. COUNTY OF DEATH
<br />9a. RE5IDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall
<br />~ Grand Island
<br />9d.STREETANpNUMSER
<br />9e. APT. NO 9t. ZIPCpDE 9g. INSIDE CITY LIMITS
<br />~_ YES ^ NO
<br />t0a. MARITAL STATUS AT TIME OF DEATH G~Marrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Lest, Suffix) II wife, give maiden name.
<br />^ Married, but separated ^ Widowed Q Divorced ^ Unknown
<br />Randall L.
<br />Wenz
<br />11. FATHER'S-NAME (First, Middle, Last, Sufllx) _
<br />12. MOTHER'5•NAME (First, Middle, Malden Surname)
<br />__ Sharon
<br />13. EVER IN U.S. ARMED FORCE57 Glve dates of service It yes. 14a.INFORMAN7•NAME ~~ 146. RELATIONSHIP 70 DECEDENT
<br />(Vea,^°,drunk.) no Randall L. W~:nz husband
<br />15. ME7H000F pISPOSITIpN i6a.EM8ALMER•SIGNATURE i8b. LIGENSE N0. 76c. pA7E (Mo., Dey, Yr. )
<br />^ Burial ^ ponation n Aug . 7, 2 0 0 7
<br />~I Cremation ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN 57ATE
<br />QRemoval ^Other(Speclfy) Central Nebraska Cremation, Gibbon, Nebraska
<br />17e. FUNERAL NOME NAME ANp MAILING ADDRESS (Str6el, Clty CrTown, State) 176. Zlp Code
<br />All Faiths Funeral Home 2929 S. Locust Grand Island NE 68801
<br />18. PART I. Enter the chain ofevents--tliseaaea, In)uriea, or compllcatlons--that directly caused the death. Dp NOT shier terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />resplratpry arrest, or ventricular tibrillatidn without showing the etiology, DO t:OT ASGf1EVIATE. Enis: only one cause on a line. Add additianxl Ilnes if nc•Cessary, i
<br />IMMEDIATE CAUSE:
<br />~ I onset to death
<br />//-~^' ' v I
<br />IMMEDIATE CAUSE (Final le) ~ ~ Q ~ ~ G `^ ~ ~ im YY.(Y (Q Q I
<br />5 S
<br />dl9eaeearcondglonrasultlng pUETO,ORASACpNSEpUENCEOF: I onset td death
<br />In death) ~~y;^,. J~ 1 ~ `'' /'r{{I, //pw (~ _'I yp/~/
<br />5egwntlally Ilst conditions, If (h) l/v l,.{/y TSB V ~ ~ ~~ ~ ~Wt. ~ r ~ ~ I fN• f' ~ ~~~ ~I~ K/ ~+/ ~ ~ w~`
<br />any,leadingtothacaueallsted pUETO,pRASACONSEOUENCEOF: I onset todeeth
<br />on Ilne a.
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<br />ElNerthaUNDf:RLYINGCAUSE r I ~'~''~
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<br />_ (dleaaaeorln)urythatlnKletsd
<br />tftawartteresuldnglndeeth) pUE T0, OR AS A CONSEDUENCE OF: I onseuo death
<br />IA;T
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<br />1 B. PART IL OTHER SIGNIFICANT CONpITI0N5-Condltlona contributing t0 the death but nol resulting in the underlying cause given In PART I. 1 B. WAS MEDICAL EXAMINER
<br />/7 ~ ,I ,, ne
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<br />( I N ~,~
<br />(
<br />( OR CORONER GONTgCTEp7
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<br />K I ~ 1 ^ YES NO
<br />20. IF FEMALE: 21 a. MANNER OF DEATH 21 b. IFTRANSPpR7ATI0NINJURY 21c.WA5ANAUTOPSYPERFORMED7
<br />1{
<br />)o Not pregnant within past year ~Naturel Q Homicide ^ Driver/Operator
<br />^ Pregnant at time of death ^ Accident^ Pending Investlgatlon
<br />^Pessenger
<br />^ YES ~Np
<br />^ Not pre Went, but re Want within 42 days of death
<br />9 P 0
<br />^ Sulclde ^ Could ndt ba determined ^ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Not pregnant, but pregnant 43 days to 1 year belora death
<br />k ^ Other (5peclly) COMPLETE CAUSE OF DEATH?
<br />'" Q Unknown If pregnant within the past year ^YE5 .~ NO
<br />r?i
<br />22a. PATE OF INJURY (Mo., pay, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street,lectory, ollice building, construction site, etc. (Specify)
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<br />22tl.INJURV AT WpRK7 22e. DESCRIBE HpW INJURY OCCURRED
<br />^ YES ^ NO
<br />221. LOCATION OF INJURY • STREET 6 NUMBER, ApT. N0. Clri/TpWN STATE ZIP CODE
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<br />
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<br />~ 23a. DATE OF DEATH (Mo., pay, Vr.) ~ 24e. DATE SIGNED (Mo., Dey, Yr.)
<br />~ 24b.TIME OF pEATH
<br />~ ~ august 5 _ 20 ~'
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<br />23b. DATE SIGNED Mo., pay, Yr.)
<br />23c.TIME DF pEATH N
<br />~ ~ 24C. PRONOUNCED DEAD (MO., pay, Yr.)
<br />24d. TIME PRONOUNCEDpEAp
<br />~
<br />''' E ~ i Qu (ASr ~
<br />3vr,7 1 0
<br />5 2 a'"
<br />
<br />O ) .:
<br />am ~ m
<br />'r $
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<br />' 23d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due td the cause(s) Btatad
<br />(Signature and Title) - ~ ~ 24e. On the basis of examination and/or investlgatlen, In my opinion death occurred at
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<br />. ,_ ~ . e
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<br />ace and
<br />ue to the cause(s) stated. (Signature end Title)
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<br />"~'~'~ 25. DID TOBACCO USE CONTRIBUTETOTWE ATH?
<br />~ 28e.HASORGANORTISSUEpONATIONBEENCONS106REp? 26b.WASCONSENTGRANTED?
<br />"~
<br />~° __^ YES ~NO ^ PROBABLY _^ UNKNOWN
<br />-,~: _ ^ VES A~'NO No) Applicable 1128s la NO ^YE5 NO
<br />~' 27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORONER'SPMYSICIAN OR COUNTYATTDRNEY) (Type or print)
<br />;.':'. Richard M. Fzuehlin MD 2116 W. Faidle Ave. Grand Island NE 68803
<br /><on, news i nHn a ~iurv,v une ~,
<br />~~
<br />29b. DATE FILED SV REGISTRAR (MO., Day, Yr.)
<br />AuG s zoos
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