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<br />STATE OF NEBRASKA 2 O i i O 1 G Q b
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPAR,TMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR,4SK.�,pEPh,f�TM�NT. DF� �-l6AL•TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FiDR� VI�,�'A4�I� '��� � r ,;,�
<br />� � `� � ", p . J
<br />�'
<br />DATE OF ISSUANCE + ,� " `
<br />„ ,. , c �
<br />� 02/17/2011 � � � �� d� � 7 P �''p � ��'' '"
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<br />i [y1r+��I�R`J�� YL�• !M�'�1�G� ' T \ L
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<br />LINCOLN, NEBR.4SKA , ' `,' ~" '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S
<br />CERTIFICATE OF DEATH
<br />E(First, qlWdle, Last, Suffix) 2
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<br />O'Neill, Nebraska
<br />SOCIAL SECURYfY NUMBER
<br />508
<br />, PACII.ITY-NAME (If not Institutbn, pive street and nun
<br />Nebraska Heart Hospitai
<br />CITY OR TOWN OF DEATH (MClude Zip Coda)
<br />Lincoln 68526
<br />�GE • Last
<br />rna
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<br />" '"�'����"iF.� ��� Y'� �" M4 �t��
<br />� ��� � � ���`' � ��� �✓�✓ w � e '�'t .
<br />� � ���
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<br />�� � ` r `,�� �'�,; ;'-:.� s°'f'i �00501
<br />b 3, OW'tE�QF E TH (Nb•, DiY� Yt.►
<br />le � February 14, 2011
<br />�NDER 7 DAY 6. DATE OF BIRTH (Mo., Day, YrJ
<br />M08. I DAYS � HOURS � MINS.
<br />HOSPITAL � Inpatlent
<br />� ER/OufpatleM
<br />Q�DQA .
<br />8d.
<br />6. PART 1. EMbr th� edain ot �wntr. iflWqs, Injedes. or �ampllqGoaMAat dlneGy qYad tM dwth. DO NOT �nbi tam�Inal W�Mt sueh is Gardlae arqst,
<br />nsplratory arrest, or wnMcular flbnllatlon wiMOUt sqowlnp the aUalopy. DO NOT ABBREVIATE. EMer onry om duas on a Ilne. Adtl atltlklonal Ilnes 1/ necsuary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Aspiration Pneumonia � .
<br />tllswca or conWpon nsuRmp �
<br />�� d �� DUE TO, OR AS A CONSEQUENCE OF:
<br />SeqwMlaly Iist conditlom, �+ b) Ischemic Cardiomyopathy . �.
<br />a�ry, Intlinp to tM auw HaMtl � � � � . . �
<br />on nrN a. DUE TO, OR AS A CONSEQUENCE OF:
<br />EM�rthe UNDERLYING CAUSE �) Renal Failure .
<br />(dbease or InJury that Initlah0 � .
<br />ttw evants nsu�Gnp In daath) DUE TQ OR AS A CONSEQUENCE OF:
<br />u8T d �
<br />II.OTHER SI(iNIFICANT GONDITIONS�Conditlons contributhp to the death but �rot resulting in
<br />�
<br />� 0. IF FEMALE:
<br />� � Not propnarn wtthin past year
<br />� � PropnaM at tlms oi death
<br />� � Not proppaM, but propnant wltdin u daya M Aaath
<br />a � Na praynaM but propnaM 4t days to 1 yur Wtoro Nath
<br />� � Unknown if prepnaM within tM pa�t yaar
<br />a 22a. DATE OF INJURY (Mp., Day, Yr.) 22b. TIME OF 11
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<br />�
<br />,S 22d. tNJURY AT WORK4 22e. DESCRIBE HOW INJURY �
<br />0
<br />� ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT,NO.
<br />� NaWnl � HomklM
<br />� Acddw�t � P�ndfnp MvadpaGOn
<br />� Su1cIM � CoWd not be tlatermhred
<br />22c.
<br />cinROwN
<br />� � November 4, 1929
<br />OTHER ❑ Nunirp HomeILTC � Flospke FaGliry
<br />� DecedeM's Home
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<br />APPROXIMATE MiTERYAL
<br />aiset to de9ith
<br />24 Hours
<br />Years
<br />Days
<br />onset �
<br />cause given in PART I. 78. WAS MEDICAl. EXAMINER
<br />AR CORONER CONT/�TED?
<br />❑ YES � NO
<br />IJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />❑ ves � NO
<br />21d. WERE AUTOPSY FINDINGS AVNLN
<br />TO COMPLETE CAUSE OF DEATH7
<br />❑ YES ❑ NO
<br />buildinp, constn�ction ske, etc. (BpacNy)
<br />ct
<br />faim, sVeet, hetory�
<br />STATE
<br />ZIP CODE
<br />�23a. DATE OF DEATH (MO., Day. Yr.) .. . . � 24a. DATE 3IGNE'� (6Ao Qay, Yr:} .. 246.TiMEUPDEt�CfFr - � - - . ..-
<br />� February 14, 2011 3� � �
<br />� Y 23b. DATE SIGNED (Mo., Day, Yr.) 2Sc. TIM6 OF DEATH �� k Y 24c. PRONOUNCED DEAO (Mo., Day, Yr.) 24d. TfME PRONOUNCED DEAD
<br />W J Februa 16, 2011 � 04:25 PM <
<br />� 0 !d. To tM best of my knowqdpe, tlaatb oaurrad at tM ri�m. dab md plaa ��� Yqa. On tM basis of examinatbn andlor InwrtlQaGon, ln my opiMOn Math oocurtW at
<br />and dua to the cause�s) stated. (Sip�aturo an0 TItN) ��� Ma qme, Wb and plaa and Aw to tM auWa) spbd. (Slpnalure and TItN)
<br />� James H. Wudel, MD `' � o
<br />Q YES ❑ NO [J PROBABLY � UNKNOWN � YES
<br />James H. Wudel, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />. REGISTRAR'S SIt3NATURE /� _ , . � _ �
<br />� Drlwr/Operator
<br />� Paseenysr
<br />� PWntrlan..
<br />� OtMt ($p�cify)
<br />. RESIDENCE-STATE 9b. COUNTY Yc. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />.$TREET AND NUMBER . APT. NO. 9t. 21P CODE 8p. IN81DE CtTY LMY11T9
<br />543 E. 19th 68801 � Y�s ❑ No
<br />a. AAARITAL STATUS AT TIME OF DEATM � Martled ❑ Nevar Marrled 10b. NAME OF SPOU3E �First, Mlddle, Last, Suffix) H wHe, gNe malden nams
<br />❑ nnarriea but separated ❑ v�naowea ❑ DWarced Q Unknown Jacqueline Reichstein
<br />. FATHER'S•NAME (Firsk Mlddle, Lasy Suffix) 12. MOTHER'S•NAME (First, Mlddis, Nkiden Sumame)
<br />John Herman Medlen Myrtle Mae Doolittle
<br />. EVER iN U.S. ARMED FORCES? GNe dates of servfce M Yes. 14a. iNFORMANT•NAME 14b. RELATIONaFNP TO DECEAENT
<br />FNP
<br />(res, No, or uMc.► No Ja ueline Medlen W ife
<br />. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 76c. DATE (Nb., Day, Yr.)
<br />�] Burlai ❑ Donation Michael B. Williams 1083 February 18, 2011
<br />❑ Cremation [] Errtombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br />❑ Removal ❑ Other (SpecHy)
<br />Sunset Memorial Gardens Hastings Nebraska
<br />a. FUNERAL HOME NAME AND MAILING ADDRESS (Straet, CHy w Sown, State) 17b. Zfp Cede
<br />Curran Funeral Chapel, 3005 S. Locusf St., Grand Island, Nebraska 68801
<br />NO � NOt AppNCable IF 26a b NO � YES � NO
<br />�Elt'$'�F14�IL`TA'R'afF s or �
<br />28b. DATE FiLED 8Y REt31STRAR (Nb., FYay, Yr.)
<br />February 17, 2011
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