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y ~ STATE OF NEBRASKA ~ ~,.~...,~
<br />- WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTF{vr11V~i F4U~ {`h~Al~ ~'~f~VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~E~'Akfi"I~N~' OPT N~ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.,f7~'Ti4^l RE (,)
<br />,,„.~t.
<br />DATE OF ISSUANCE ~~~
<br />~'
<br />NOV 1$ '2009 2 0 1 0 0 4 8 6 5 A~S~f,AN,T,7~~"CE RIEC~~~''~RA{~ !
<br />D,ti•'1(~~d1Rf?7'ME'NT OF HEAL'~"H AND ,
<br />'~ LINCOLN, NEST~~ OF NEBRASKA -DEPARTMENT QF HEALTH AND HUMAN SERVICESp~~-9~~CE,~ ~t'~.~}~ ~ f .Y. .
<br />s CERTIFICATE AF 17FOTH r c~
<br /> 1. DECEDENT'S-NAME (Pint Mlddia, Last, BuNlx) 2. 8EX 3~ ATE GIFIDF,.ATF1•(MO~y,Yr,}.
<br />
<br />AIIen Robert Fritz
<br />Male rL j '/ + '
<br />No~eRhb r.4,$~Op4~"
<br />i 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lear 8lnhday 64. UNDER 1 YEAR 5c. UNDER 7 DAY 8. DATE OF'BIRTH (Mo„ Day, Yr,)
<br /> (Yrs.) MOB. DAYS HOURS MINB. ,
<br /> Ynrk, Nebraska 58 January 3, 1951
<br /> 7. SOGIAL SECURITY NUMBER Ba. PLACE OF DEATH ~
<br /> 505-fib-9559 MOSpITAL: ^ Inpatlam OTHER: ®Nurslrtg HamaILTC ^ Hasplca Facility
<br /> 84. FACILITY~IAME pf nw IMtttutlan, give sheet and number) ^ ER/OutpatNm ^ Decadam's Moms
<br />V
<br />C` "'RAt~eSt' vClVertard t1dlTTe " ... _ .._.... .. _. . _ „ , :._._ ^ DOA ^ Ottrer(Spacify) ....
<br />
<br />D
<br />ec. CITY OR TOYYN OF DEATH QncWde Zip Coda)
<br />8d. CDUNTY OF DEATH
<br /> Stromsburg 88666 Polk
<br /> 9a. RESIDENCES7ATE $b. COUNTY gc. CITY OR TOWN
<br /> Nebraska York Waco
<br />~
<br />, 9d. STREET AND NUMBER 9a. APT. NO. gf. aP CODE $g. INSIDE CITY LIMITS
<br />~ 1813 Road W 684fi0 ^ Yea ®No
<br /> 10a. MARttAL STATUS AT TIME OF DEATH ®Marrlad [~ Navar Married tab. NAME OF SppUSE (First, Mitldu, Last, Suffix) If wHe, give maiden name.
<br />W ^ Marrlad, but separated ^ Widowed ^ Divorced ^ Unknown '
<br />
<br />ar Alice l,.
<br />OOk
<br />~' 17. FATHER'S-NAME (First Mlddia, Last, Suffix) 72. MOTHER'S-NAME (Pint, Middle, Malden Surname)
<br />0
<br />w
<br />Ivan Fritz
<br />Mildred Prochnow
<br />m
<br />p
<br />m 13. EVER IN U.ffi. ARMED FDRCE87 Give date! of 9ervlca tt Yae. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO pECEDENT
<br />t7
<br />~
<br />(Yes, Na, «Unk.) NO
<br />Alice Fritz
<br />Souse
<br /> 15. METHOD OF pIBPOSITION 16a/EMBA ER-SIGNA URE _ 184. LICENSE ND. 78c. PATE (Mo., Day, Yr.)
<br /> ®aaA.l ^oon,aen ~--~. ~``
<br />
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<br />s
<br />¢ ~ November 9, 2009
<br /> nme
<br />on ^
<br />ntvmament
<br />^Remov.l ^Olh.r/speray)
<br />t8d. EME ~, CREMATORY OR OTHER LOCA ON CITY/TOWN STATE
<br /> Immanuel Cemetery Utica Nebraska
<br /> 77a. FUNERAL HOME NAME ANp.MAIUNG ADDRESS (Street, City w Town, Stara) 17b. Zlp Code
<br /> Volzke Mortuary, 147 Main Street, Seward, Nebraska fi8434
<br /> CAUSE OF DEATH See Instructions and exam les
<br /> 16. PART 1. Enter lha eheln or wants- diMewe, InlurNe, ar compllcatlen.-1Mt dlwetry aaYNd Poe da.tlr. OO NOT.nMr rmmN rvrnh .ueh .. e.rd111a 11mn, APPROXIMATE INTERVAL
<br />neptetory emet ar venerlculer Rbnaesan Weheut ehoMlna the etkNOyy. DO NOr ABBREMA7@. Enbr anry one eauae m . pne. Add eddNonel anew a neweeery. 1
<br />- ~ -.- - ~ IMNIEDIA7E CAtI.iG: ~ 1
<br />__,.. ......_ _... _.... _ .... ---'_.., __....._ .. 1 tsyet to death
<br /> IMMEDIATE CAUSE (Final ~ '
<br /> disease a condition rdeutting a) ~ ~
<br /> In death) r r
<br /> DUE 70, OR AS A CONSEQUENCE OF: 1 0 to death
<br /> $aquardlally Ilst conditions, If ~
<br />b)
<br /> any, leading to the cause listed
<br />~
<br /> on Iina a. DUE 70, OR AS A CONSEgUENCE OF: , olyet to death
<br />1
<br /> Erder the UNDERLYING CAUSE C) ~
<br /> (disease a In)ury that initiated '
<br /> the events reautting In death) DUE 70, OR AS A CDNSEOUENCE OF; 1 onset to death
<br /> LAST 1
<br />r
<br /> d) ~
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONSConditlory contributing to the death but not resulting in the undadying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />
<br />K ^ YE8 ^ NO
<br />W 2g. IF FEMALE: 21a. M R OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pregnant wtthln past year atural ^ Hnmlclda ^ Driver/Operator ^YE8
<br /> ^P
<br />t
<br />t ti
<br />f
<br />~ regnen
<br />a
<br />me o
<br />death ^ Acciderd [~ Pending IrnesUgatlon [] Passenger
<br />
<br />[J
<br />^ Not pregnant but pregnam wtthin 42 days of death
<br />^ Sulclde ^ Could ewt be determined
<br />^ Pedasvlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />~`
<br />^ Not pregnam, but pregnara 43 days to 7 year before death
<br />^ Other (Spaclty) TO COMPLETE CAUSE OF DEATH?
<br />^ YES ^ NO
<br /> [Unknown if pregnam wtthln the peat year
<br />d
<br /> 22r. DATE OF INJURY (Mo., Day, Yr.) 224. TIME OF INJURY 22c. PLACE OF INJURY-At harry, farm, street factory, OfRce bulldheg, corestructlon stta, etc. (Specify)
<br />t~ m
<br />
<br />
<br />
<br />O 22d. INJURY AT WORK?
<br />
<br />- 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />~_ .. ._ .. ~.. _ _ ~ _ _ - _ -- - .~ _._~ _ __~. _ - _ -~~~_ __~. _.. -- -
<br /> -_ {] YES pTao
<br /> 22f. LOCATION OF INJURY - STREET b NUMBER, APT. NO. GITYROWN STATE DP CODE
<br /> 23a. DATE OF
<br />EATH (Mo., Day, Yr.) Z 24a. DATE SIGNED (Mo., Day, Yr.) 244. TIME OF DEATH
<br /> {
<br />~~ ~ C
<br /> ` C1Z m
<br /> ~ 234. DATE SI N O (M ., Day, Yr.) 23c. TIME OF
<br />TH m }
<br />24c. PRONOUNCED DEAD (Mo.
<br />Day
<br />Yr
<br />) 24d
<br />TIME PRONOUNCED DEAD
<br /> awl
<br />I ~ ~
<br />,
<br />,
<br />.
<br />i6 x >
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<br /> ~6 0
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<br />d , m iy`= m
<br /> aa
<br />m U 23d. ro the beat n ga, ash Occurred al lha tkna, data a d place W 2 ~ 2le. On the baste of examination and/or ImaatlgstlOn, In my opinion death accurrad
<br /> a w and duet he a stet . (Signature and TRIB)
<br />~~ $' ~ pp7 at the time, data and place end dup to the cause(s) stated. (Signature and TMIe-
<br />H
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<br /> 25. OID TOBACCO SE CONTRIBUTE TO THE DE ? 26a. HAS l7ROAN DR TISSUE DON .BEEN CONSIDERE07 284. WAS CDNSENT GRANTE07
<br /> Q YES ~ NO ^ PROBABLY NKNDWN ^ VES r NO NM AppgCable If 28a Is ND ^ YES ^ NO
<br />- ``
<br />J 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHY8ICIAN OR COUNTY ATTORNEY) (Type a PflM)
<br /> Erwin Joseph M. D. 2114 N. Lincoln Ave. York, NE 68457
<br /> 2$a. REGISTRAR'S SIGNATURE 284. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />P NOV 16 2009
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