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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN�•�M(l�e'1Aly SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK�4*�CSEPAI�TMEN7$ �F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI'�AL.#�EC�RDS �,
<br />,�,����� ,�'�`
<br />DATE OF ISSUANCE �"'''ly - <' � �
<br />11 /03/2010 2 011 U� 8�. � S TANL�Y 5. CODPE72 .
<br />ASS�STAN T3TA�E �tEGISTRAR" ":
<br />DEPART.ME�lF O�:HFi�L.TH AI1FD
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICflS '•' �._ � O O3'I'I3
<br />CFRTIFICATF (1F 11FATH �
<br />7. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX S: DATE OF DEATH (Mo., Day, Yr.)
<br />Lester Louis Petzoldt Male October 28, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAVS HOURS MINS.
<br />Merrick County, Nebraska 80 February 19, 1930
<br />7. SOCIAL SECURI7Y NUMBER Sa. PLACE OF DEATH
<br />506-28-0641 HOSPITAL � Inpatient OTHER ❑ Nursing Home/LTC � Hospice Fac(Iity
<br />Sb. FACILITY-NAME (If not Institutlon, give street and number) � ER/Outpatient � DecedenYs Hame
<br />�
<br />� 4020 West W hite Cloud Road ❑ DOA ❑ Other(Specify
<br />� Sc. CITY OR TOWN OF DEATH (Indude Zip Code) r �� ` � 8d. COUNTY OF DEATH ���� .��� ______.�...._._.__
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />z
<br />LL 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />T 4020 West White Cloud Road 68803 ❑ YES � No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 70b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />�
<br />m
<br />!E ❑ Married, but separated ❑ Widowed ❑ Dlvorced ❑ Unknown Myrna Anderson
<br />`
<br />,2 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />� Henry Petzoldt Ella Mettenbrink
<br />°' 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT•NAME 144. RELATIONSHIP TO DECEDENT
<br />E
<br />� �ves, No, or unk.) Yes 05/17/1954-04/12/1956 Myrna Petzoldt Wife
<br />� 75. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />� � Burial ❑ Donatfon
<br />Chris McCoy 1191 November 1, 2010
<br />❑ Cremation ❑ Entombment �6d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, SWte) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />18. PART I. Enter the chaln of events--tliseases, injuries, or complications-that dlrectly caused the death. DO NOT entei terminal events such aa wrdiac arrest, ; APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular Flbrlllation wlthout showing the etiology. DO NOT ABBREVIA7E. Enter only one cause on a Iina. Add additional flnes If �ecessary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATECAUSE�Final a) Respiratory Failure ;< 1week
<br />disease or condition resulNng
<br />tn death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentially Iist conditions, �r b) Metastatic Squamous Cell Cancer Of Head And Neck ; Approx 7 Years
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enterthe UNDERLYING CAUSE �)
<br />(disease m injury that INtlated
<br />the events resulting tn death� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />LAST d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditlons contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />Aspiration Pneumonia OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATtON INJURY 21c. WAS AN AUTOPSY PERFORMED7
<br />LL
<br />F- � Not pregnant within past year � Natural � Homicitle � Driver/Operator
<br />� ❑ YES � NO
<br />U � Pregnant attime of tleath � pccident � Pending Investl9ation � Passenger
<br />T � Not pregnant, but pregnant within 42 tlays of death � Pedestrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Suiciae � Cowtl not be determined TO COMPIETE CAUSE OF DEATH7
<br />, � Not pregna�t, but prepnant 43 days to t year before tleath � pther (Specify)
<br />:% � Unknown ii pregnant within the past year ❑ YES ❑ NO
<br />d
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />E
<br />0
<br />u
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ YES � NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z � 24a. DATE SIIiNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a w October 28, 2010 e<_ w
<br />a� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m�� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E v Z OCtOb2f 29, 2010 05:06 PM E a a Z
<br />w
<br />� � � 29tl. 7o the best of my knowletlge, Aeath occurred at the time, tlate and place �� Z O
<br />W 24e. On the basis of examination and/or fnvestipatlon, In my opinlon tleath occurred at
<br />0 o and due to the cause�s) stated. (Sipnature and Title) a 0 � the lime, date and place and due to the cause�s) slatetl. (Signature an0 Title)
<br />~� Jennifer L. Brown, MD ~ �;
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH4 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED7
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES � NO Not Applicable N 26a is NO Q YES ❑ NO
<br />27. NAME, TITLE AND ADDRE OF ERTIFI R(PHY 1 IAN, HYSI IAN SI TANT, R NER'S PHY I IAN R UNTY A N )(Type or Print)
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 2, 2010
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