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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND"h/UMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM THE NEBRA$KA• D~PA~4~MEIVT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R€COR~~ ;_• ~ ~ •
<br />DATE OF ISSUANCE ~e , ,
<br />o~G o s Zaas St~~~>Y ~~~ -
<br />20100000 ~~P~~~ME~TVTa R M
<br />LINCOLN, NEBRASKA H41M~410 ,~~`k~f1,~~~ -
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<br />rural Adams County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
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<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICE$~ ti, ~ •
<br />TIFI F D X638 ,
<br />1. bECEDENTB•NAME (Pint Meddle, Last Su1Rx) 2. SEX ~ 3. DATE OF DEATH (MO.,Pay,Yr.~.
<br />l]arrel G Rewerts Male May 7, 2008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 91RTH Sa. AOE•Last Birthday efb, UNDER 1 YEAR tk. UNDER 1 DAY 0. pATE OF BIRTH (Mo., Day, Yr.)
<br />8b. FACILITY-NAME (N net InellWtlon, gin atnet and number)
<br />13280 South Monitor Road _ ---_ _-.
<br />tk. CITY OR TOWN OF pEATH pnclude Zlp Coda)
<br />Doniphan 68832
<br />>ti. RESIDENCE,$TATE eb. COUNTY
<br />Nebraska Hall
<br />8d. $tREET AND NUMBER ~~• ~-~
<br />13280 SDUth Monitor Road
<br />18a. MARITAL STATUS A7 TIME OF DEATH ®Maued ^ Navar Mal
<br />^ Mauled, but saparabd ^ Widowed ^ pwnrced ^ Unknown
<br />11. FATHER'S•NAME (Pint Mlddla, Last SulRx)
<br />Francis Rewerts
<br />1Yn.1 MOS. DAYS HOURS MIN$.
<br />fig November 5, 1938
<br />ea. PLACE OF DEATH
<br />tti ^ Inpstlent OTHER: ^ Nuninp HomdLTC ^ Mospica Facility
<br />ERK)utpadeM ®Decedsnt': Hama
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<br />8d. COUNTY OF bEATH
<br />Hall
<br />gc, CITY OR TOWN
<br />9a. APT, N0. W. ZIP CODE 90. INSIDE CITY LIMITS
<br />68832 ©YN ®No
<br />106. NAME OF SPOUSE (Pint, Middle, Last $u1Rx) N wile, give twlden name.
<br />Patricia Plsczek
<br />12. MOTHER'S•PIAME (First Mlddk, Maiden Surrlama)
<br />Elfrieda PaoenhaGen
<br />1J. EVER IN U.B. ARMED FpRCE$7 Glva dates of aarvke N Yw. 14a. INFORMANT•NAME
<br />(Yae,No,nrunk.XPs Patricia Rewel't3
<br />1t1, METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE
<br />^eur61 ^°an""°" Not Embalmed
<br />~Cnmllean ^Etd°m6mam
<br />^Remoral []dm.naP.dryl 18d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Service
<br />17a. FUNERAL HOME NAME ANO MAILING AbbRE$$ (Street CNy or Town, State)
<br />Brand-Wilson Funeral Home, 505 N Bellevue, Hastings, Nebraska
<br />146. RELATIONSHIP TO DECEDENT
<br />Wife
<br />1 eb. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />Ma 8, 2pt78
<br />GITYn"OWN STATE
<br />Gibbon Nebraska
<br />176. Zip Cod.
<br />689p1
<br /> CAUSE OF DEATH See Instructions and exam les) -~
<br /> ta. PART 1. ElxeriM ~aln°r~vMd.tllesaaae,WPd"e,.or cMnpllCaUOne•ihrt dlnAly pepdae-MMh.O4NOieaMrtanwaYevMA"ieMINeM~alae'erNM,
<br />Iwplrat°ry Meal. ar ren61¢Iarr a6naaeon wkhoul gwwlne iM NlelesY• OO NOT Al6NlVlaii. BrMr etllY txte~cauae °n a one. Add addakrtW anea H rrpeeatY.... ~ INTE AL
<br /> IMMEDIATE CAUSE: : omet to dwlh
<br /> IMMEDIATE CAUSE (Final
<br /> dhgN MCOtIdRlnn ruyhlnp a) cardiac arrest
<br />In death)
<br />'unknown
<br /> DUE TO, OR AB A CONSEQUENCE OF: ; onset b death
<br /> Srquentlaly Ilet condlllons, N
<br />alry,lwdlnptothecau.euaal b) heart disease
<br />:unknown
<br /> on Ilne a. L'UE TO, OR :.S Tl
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<br />.•:aCEgl'cNCE OF: ~~ oneoc to oeatn '~
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<br />Enlsr the UNDERLYING CAU9E C) high b10od pressure ~ 30 years
<br /> --- ~
<br />(dlswse or In)ury that Initiated - _,,...,,~..
<br />the wend nsultlnp In dwth) DUE TO, OR AS q CONSEQUENCE pF;
<br />~ onsd to dwlh
<br /> LAST
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<br /> 1B. pART IL OTHER SIGNIFICANT CONDITIONS•Conditlona cantrlbupnp to the death put not rosulting In the underylnp taus. piven Id PART 1. 19. WAS MEDICAL EXAMINER
<br /> _ OR CORONER CONTACTED?
<br /> ~ YES ^ NO
<br />~
<br />W 28. IF FEMALE: ~ 21a. MANNER pF pEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pnpnant wlthln pant ywr ~Nabini ^ Homicide [] DHveHOpentor ^ YES ®NO
<br />yt ^ PrepnaM at tbna or death ~ , ^ AccldeM ^ Pandlnp ImugpaNon ^ Passenger
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<br />[,] Not prapnant but prognant whhln 42 day. of dwM
<br />^ Suklde ^ Could not de dahnnirod
<br />^ pedestrian 21d. WERE iIUTOPBY FINDINGS AVAILABLE
<br />
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<br />^ Not prapnattf)but pregnant 47 days to 1 year 6elon des
<br />^ Other (SpecHy) TO COMPLETE CAUSE OF pEATHT
<br />^ YES ®NO
<br /> ^ Unknown H prapnant wlthln the put ywr
<br />a
<br />22a. GATE OF INJURY (Mo., Day, Yr.) 224. TIME OF INJURY 22c. PLACE OF INJURY•At horror, larm, strwt tactvry, ollka 6uitdinp, conatmcpon site, ata($pecly)
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<br />m 22d. INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
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<br />t' ~ ^ YES ^ NO
<br />221. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO. CITYlTOWN STATE ZIP COQE
<br />47a. PATE OF DEATH (Mn., Day, Yr.l 24a. PATE SIGNED (Mn., Day, Yr.) 24b. TIME OF DEATH
<br />~'~ ~'~~ May 22, 2008 8:20 a m
<br />2E6. DATE SIGNED (Mo., Day, Yr.) lac. TIME OF DEATH ~ ~ ~ r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 44d. TIME PRONOUNCED DEAD
<br />ar ~~~ J
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<br />e~ 29d. To the boat o/ my kntlwkdpa, death occuuad at the Uma, dab and place ~ 44a. On the dada of sxaminsgon andlor tnveetlgadon, In my oplnlen dwth occumd
<br />and due to the cause(s) sbbd. (Slpnawn and tltb) ,~ at ha tl and place and due to the teasels) staled. (Slpnatun and Tltbl
<br />w a ~ t, ~ Hall County Atto'
<br />2a. pip TOBACCO USE CONTRIBUTE TO THE pEA7H7 28a. HAS ORGAN OR.71$$UE DONATION BEEN ED7 486. WA$ CONSENT"GRANTED?
<br />~.... ^ YES [~NO ^ PROBABLY ^ UNKNOWN ^ YES ~ NO Not Applicable II 28n W NO ^ YE8 ~ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ('Type or PHnU
<br />Mark J. Young, Hall County Attorn y, 231 S. 4 ust St., Grand Island, NE 68801
<br />28a. REGISTRAR'S SIGNATURE 28b. pATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />P ~` MAY ~ 8 2008
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