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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A;~?A~I $EI~KIL~S
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN~EEQ~t¢Qlfi•k~i,E W ~ . -
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA~5T1~S ~L~'~T/O/11,~NffK:H /3
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - ' • -
<br />DATE OF ISSUANCE m = ~,
<br />MAY 1 6 2006 2 010 0 2 5 2 5 ~~: ~_= ~.~~~. ~~~~
<br />sisT,~Nr STATE ~r~isr~raR
<br />LINCOLN, NEBRASKA HE.~4„TH AI~Q:N_SE~CES
<br />=- --_. - = _tic ..
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESPINANC~ AND SUPPORT
<br />_ CERTIFICAT(= OF DEATM ~ " ~~
<br />1. DECEDENT'S•NAME (First, Mlddle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day,Yr.)
<br />Ph llis M. Wetzel Female Ma 9 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIQN COUNTRY OF BIRTH ea. AGE•Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 5. DATE OF BIRTH (Mo., Day, Yr.)
<br />(yrs.) MOS. DAYS HOURS MINE.
<br />Zissouri Valle Ir~Wa 76 - 3 13 ._ January 21 , 1930
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />)Q6-30-4307 „_ f H,QSPITAL: ~11npatlenl 4I)jER: l.aNursingHomelLTC ^HvspiceFacllity
<br />Bb. PACILITY•NAME (If not Instltutlon, glue street and number) ^ ER(Outpatlent ^ Decedent'sHoma
<br />Bryan LGH East I ^ ppq ^ Other(Specily) -~-_
<br />Be. CITY OR TOWN OF DEATH (Include ZIp Coda) J~ Bd. COUNTY OF DEATH
<br />Lincoln __ - _. Lancaster -
<br />9a.RESIDENCE-STATE M 8b.000NITY 9c. CITY OR70WN
<br />Hall Grand Island
<br />Nebraska ~-. -_.,
<br />Sd.57REETANDNUMBER ge.APT.NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />1322 _Sheridan Place 63$03 ._ Yp YES ^ ND
<br />iaa. MARITAL STATUS AT TIME OF DEATH C}[Married ^ Never Married ~ lob. NAME OF SPOUSE (Flrsl, Mlddle, Last, Suiflx) I1 wife, give maiden name.
<br />~;w",.,r ar e~rfiad ~l w.y; sr,
<br />~MeMed, buts T ;~. ,~.++~
<br />H 11. FATHER'S•NAME (First, Mlddle, Last, Sufllx) 12. MDTHER'S•NAME (First, Mlddle, Malden Surname)
<br />y ., Vera Neufind
<br />~.: it S rrs . ,~ -
<br />13. EVER IN U.S. ARMED FORCE31 Glve dates of service If es. 14a INFORMANT•^ E 14b. RELATIONSHIP TO DECEDENT
<br />~~ : (Yes, no, or unk.) ` H zel _ Husband
<br />"' 15. METHOD OP DISPOSITION 16a. EMBA MEp~ NATURE __ -_ __. ~ 18b. LICENSE NO. 18c. DATE (Mo., Dey, Yr. )
<br />~''~' ~ -• Ma 8 2006
<br />.~7 Burial ^ Donation .Q.~. ...
<br />~'~- 16d. CEME RY, CREMATORY OR OTHER LOCA710N CITY! TOWN STATE
<br />e~ ^Cremalivn ^Enlombment
<br />$ ~~~ ^ Removal ^ other (speafy) Grand Island City Cemetery, Grand Island Nebraska
<br />17a. FUNERAL HOME NAME ANO MAILING ADDRESS (Street, Chy orTown, State) 17b. Zi Coda
<br />~~ Trivingston-5ondermann Funeral Home, 601 N. Webb Rd., Grand Island, ~ 6803-4050
<br />.~,
<br />1I1.,PART I. Enter the chain of evenLa•-tllseases, In(urles, or compllcations•-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br />Sit; reaplralory arrest, or ventricular ti6rlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only ane cause an a Ilne. Add additicnal Imes If necessary. I
<br />...,.~ I onset to death
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(Flnal (a)_ •
<br />dlseasaorcondltlonresulling pUE 70, OR AS A CONSEQUENCE OF: ~ I vnsettodeath
<br />r.~~ In death) ~
<br />~'~ Sequentlallyltafcandltlona,if l6) ,.-_ _ ,,, ..._, -~~ I -
<br />eny,leadingtothecausellated DUE TO, ORASACON5EQUENCEOF: I onset to death
<br />cn Ilne a. I
<br />Entardte UNDERLYING CAUSE I
<br />~ ~~ (dlseaseorln)urythetlnttlalad (c) - --- I-~ -•- --
<br />'~` theevenlsresultlngtndeath) ~~ I anseltodeath
<br />~'a DUE T0, OR AS A CONSEQUENCE OF:
<br />IASf I
<br />' I
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS•Candltlons conirlbuling to the des h but not res Iting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />~ ~ c~~~T~ ~ ~~~ ~ I ~ C ~~p t11 „ - , .~~~. . O ~L'~,(~~ ~~~I~~ ~1~,~, OR CORONER CONTACTED?
<br />y[-'a'yLY V~-C/ C•1 VYt "~.Y'-~_ • V I \ C~ YES ~.... 0 - --
<br />~~-~ ~2p.IFFEMALE: 21a.MA NEROPDEATH 21 b. IF7RANSP TINJURY 21c.WA5ANAU70P5YPERPORMED7
<br />.~ ;I tural ^ Hamlcide~ ^ Driver/Operator ` ,
<br />°~~ ~ipregnantwithlnpa9tyear /// ^ YES L~110.
<br />A ^ Passenger
<br />? V... ^ Pregnant at time of death U Accldent^ Pending Investigation
<br />` ^Pedeatrlan 21d.WEREAUTOPSYFINDINGSAVAILABLETO
<br />`~ -. ^ Nol pregnant, but pregnant wllhln 42 days of death []Suicide U Could not be determined
<br />(..)Other (Spedify) COMPLETE CAUSE OF DEATH?
<br />^ Not pregnant, but pregnanl43 days to 1 year before death
<br />- ^ Unknown If pregnant within the past year _•-_ LJ YE5 ~10
<br />~~- 22a. DATE OF INJURY (Mo., pay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, sire9t, factory, ofllce building, consirucllon site, etc. (Specify)
<br />~~S m
<br />-~ 27.d.INJURYATWOpK? 22a.DESCRIBEHOWINJURY000URRED
<br />^ YE5 (J NO ,. ...
<br />221. LOCATION OFINJURY -STREET & NUMBER, APT. N0. CITY(rOWN STATE TIP CODE
<br /> 23a. DATE OF DEATH (Mv., Day, Yr.)
<br />W 24a. DATE SIGNED (Mc., Day,Yr.) 246.TIME OF DEATH
<br />m
<br /> ~~
<br />~ -
<br />~' -May 4. 2,006 - TIME PRONOUNCEb DEAD
<br />24d
<br />` ~ y 236. DALE SIGNED (Mc., bay, Yr.) 23c.TJM~ OFOP~ATPM
<br />-- ~ a ~ 7
<br />x
<br />a~ 24c. PRONOUNCED DEAb (Mo., Day,Yr.) .
<br />m
<br />~a~ T
<br />f ~u ~~ ~t~C?~c' II
<br />m ~ ~
<br />~ ~
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<br />~ 23d. to the best of my knowledge d th occ rred at the time, date and place
<br />d Title) •
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<br />~
<br />~ 24s. On the basis of examination and/or invastlgation, In my opinion death occurred at
<br />the lima, data and place and due to the cause(s) stated. (Signature and Title)
<br />_
<br />,
<br />o ~ g ure an
<br />ad (
<br />and due to the cause(s) stA ~
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<br />' 25.DIDT08A000USECONT ETOTHEDEATH? 28a.HASORGANORTISSUEDONATIONBEENCONSIDEREO? 28b.WA5CON5ENTGRANTED7
<br />'0 ^ PR08ABLY U UNKNOWN
<br />~ ^ Q YES Not Applicable if 26a le NO ^_ YES NO
<br />L
<br />YE5
<br />27. NAME,TITL6ANDADDRE550FCERTIFIER (PHYSICIAN,CORONER'SPHYSICIANO ~UNJ RNEY) (TypaorPrlnq
<br />~~~'~~
<br />~` Tamer Mahrous, NID !~?~Jd •.~v41~ ~~ ~t ~. ~ L l ~-
<br /> ay, Yr.)
<br />(pggy
<br />28b. GATE FILED eY REGIST,FIA
<br />28s. REGISTRAR'S SIGNATURE /~
<br />® /1 / 1 i'a ~
<br />~
<br />1AYAfAY yA 'sJa Uu
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