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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ~4/VQ HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.4blt'.~ D~€€PARFI~'1ENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR •V~~1~~`RE~'C~Rl~S'
<br />DATE OF ISSUANCE ~~~~ ~,:,~
<br />n " ~`rANLEY S"L60PER ~'. - ,~,.i
<br />01 /27/2010 2 U 1 Q U l v 5 8 n~srs~any~srAT~,~~crSfiRaR
<br />'L?EPAFaF~'lE~l',Ts ~I~LT~i4NtJ
<br />LINCOLN, NEBRASKA ', -HUMAN SERVICES ;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S~I~V14~Q$ - ,
<br />•.~~r~.`.:'.:~'1.,.~ y:. _ 10 00181
<br />CERTIFICATE OF DEATH y ,. ~';,~
<br /> 1. DECEDENT'S•NAME (First. Middle, Last, Suffix) 2. ~
<br />' v// f ~ •, 3. DATE EATH (MO., pay, Yr,)
<br /> Harold Dean Renz ~
<br />f
<br />Male` °,. ., ~ ,January 24, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 7 YEAR 5c. UNDER 1 DAY e. DATE OF 91RTH (Mo., Day, Yr.)
<br /> IYn•I MOS. DAYS HOURS MINE,
<br /> Hot Springs, South Dakota 76 October 19, 1933
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 504-34-0413 HOSPITAL ^ InpatleM OTHER ®Nursing HomelLTC ^ Hospice Facility
<br /> eb. FACILITY-NAME (If not Institution, give street and number) ^ ERlOutpatient ^ Decedent's Homa
<br />
<br /> Grand Island Veterans Home ^ DOA ^ Other (Specify)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />S Grand Island 68803 Hall
<br /> 9a. RESIDENCE•3TATE 9b. COUNTY 9c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER . ApT. NO. gf. ZIP CODE 9g. INSIDE CITY LIMITS
<br />a. 1818 W 10th Street 68803 ®Yes ^ No
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Marrlad ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, SufFlx) IT wHa, give maiden name
<br />
<br />m ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown PhylllS Mertz
<br /> 11. FATHER'$~IAME (Pint, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middla, Maiden Surname)
<br /> George Renz Marie Kienitz
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Giva dates of service If Yes. 74a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />s (Yes, Nd, or unk.) Yes 05/07/1953-04/30/1955 Ph Ilis Renz Wife
<br />at
<br />A 75. METHOD OF DISPOSITION 78a. EMBALMER-SIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />f~, ^ Burial ^ Donation
<br />
<br />® C
<br />Not Embalmed
<br />January 25, 2010
<br /> remation ^ Entombment
<br />^ Removal ^ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> Smithwick Cemetery Smithwick South Dakota
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (SVeat, City or Town, State) 17b. Zip Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> F DEATH ee nstructions an exam les
<br /> 78, PART L Enter the chain of events--dlteasea, Injuries, or complicationsthet directly caused the d6ath. DO NOT solar terminal 9yents such as cardiac arroffi, AppROXIMATE INTERVAL
<br /> respiratory arrest, dr venMcular flbrlllatlon without showing the etiology. DO NOT ABHREVIgTE. Enter only ono wuae on a Iina. Add addltlonal Ilnaa II necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Parkinsons Disease ;Years
<br /> dlseate Or condltlon roaubinq
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequantlally Ilst cdntlitlana, if t)1
<br /> any, leading to the cause listed
<br /> on Iins a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or In)ury that Inhlatad
<br /> the events resulting In deatnl DUE TO, OR A8 A CONSEQUENCE OF: onset to death
<br />LAST
<br /> d)
<br /> 18. pART II.OTHER SIGNIFICANT CONDITIONS•Condltions contributing to the death but not resulting In the underlying cause given In PART 1. 79. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTEDT
<br />qn ^YES ®NO
<br />~ 2D. IF FEMALE: 21a. MANNER OF pEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Ndt pregnant within peat year ®Natural ^ Homicide ^ Drlvsr/Operator
<br />
<br />U ^ YES ®NO
<br />^ Pregnant at time of death ^ Accident ^ Psndlnq Investigation ^ Pastwngsr
<br />
<br />~" ^ Ndt prognam, but pregnant within 42 days oT death ~ Petlestnan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />~ Suicide ^ Cdultl not bs determined
<br /> ^ Not pregnant, but prognant 47 days to 1 year before deMh [] Otlwr (Specify) TO COMPLETE CAUSE OF DEATHT
<br />~ ©Unkncwn if prognant within the past year ^ YES ^ NO
<br />E 22a. PATE OF INJURY (MO., Pay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, facto
<br />ry, office building, Constructlan site, etc. (Specify)
<br />
<br />'
<br />~r 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~
<br />^YES ^ NO
<br /> 22f, LOCATION OF INJURY • STREET & NUMBER, APT.NO. GITYlTOWN gTATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />~' W Jan
<br />24
<br />2010
<br />3 ~
<br /> uary
<br />,
<br />~
<br /> r tab. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ~ ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED pEAD
<br /> ~
<br />~ W ~ Janus 26 2010 11:43 AM E d
<br />E c+ z H
<br /> ~ Jd. To the best o! my kndwladge, death occurrod at the time, date and place $ W ~ O $4a, On the basis oT axaminatldn andldr Investigation, In my opinion death occurred at
<br />and due to the Cabaels) stated
<br />(Sl
<br />naturo and Tltl
<br />g
<br /> .
<br />g
<br />s)
<br />~ p the rims, data and plats and due to [ha cause(s) hated. (Slgnaturo and TIt19)
<br /> ~ Gene L. Wyse, DO ~ ~ 6
<br /> 25. OID TOBACGO USE CONTRIBUTE TO TWE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREp? 26b. WAS GONSENT GRANTED?
<br /> ^ YES ©NO ^ PROBABLY ® UNKNOWN ^YES
<br />® NO Not Applicable iF 28a Is NO ©YES ^ NO
<br /> 2 A D FI ( HY E N ype or rant)
<br /> Gene L. Wyse, DD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mp., pay, Yr.)
<br /> January 27, 2010
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