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STATE OF NEBRASKA
<br />, WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVZCES, IT CERTIFIES
<br />THE BE40W TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAI3EPARTM�IVfi OP MEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL t ,R��71�D9 ��;� � �' 3 h
<br />� �ry
<br />� � a,
<br />DATE OF ISSUANCE � �
<br />���r�����hV" [J � a'� �', i� ' ,
<br />' 10/28/2010 . 9 E n � sran�e�e� s. co�PC-s� '; �. " ; ,1 .
<br />iGr U J- 1 O�`� �. /•+ ASS,�'S7`ANT,�F�E RE STRi9Id�' .�' :,.
<br />DEPARfiME7�� �U� HE'AL�1� �4NlJ�_' `+ _
<br />LINCOLN, NEBRASKA HUMA11P,5�1�1lICE�,5 �?;:; , ,`. ;�'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, �"•. �°�� ` '��-' ��'
<br />r_Fari�irer� nG n�eru ,� ' '���'� °° '.`••',, �� �0 03035
<br />-- - - - -- ,�,� _
<br />1. pECEDENT'&NAME (Flrst, Middle, Last, Suffix) 2. SIX ,. ,0, DATE,OF DEATM{Mo., Day, Yr.)
<br />Peter Lavern Pittz Jr Male � pctober 24, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Blrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MO3. DAYS HOURS MIN3.
<br />�Assumptlon, Nebraska 77 January 14, 1933
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />'�505 HOSPRAL � InpaUerrt OTHER � Nursing Home/LTC � Hosplee Facltlty
<br />81r; FACILITY•NAME pt rrot Instltution, glve atreet and number) ❑ ERIOutpaUe�rt ❑ Decedent's Home
<br />�
<br />� 'Saint Francis Medical CQnter _ ___ ❑ ooa
<br />❑ Other (Specify)
<br />- -- - _ . _._ _ - - - -- - ' - - -- --�-� -..�_
<br />� 8c: CITY OR TOWN OF pEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a: RESIDENCE�9TATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9ds STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY UMITS
<br />�, 312 E. Bismark 68801 � ves ❑ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Naver Martled 10b. NAME OF SPOU9E (First, Middle, Last, SuffUc) It wife, gNe matden name
<br />�
<br />� �Ip mamaa but separated p vuiaowaa ❑ Divorced ❑ Unknown EUen Gannon
<br />� 77', FATHER'S-NAME (First, Middie, Last, Sufffz) 12. MOTHER'S-NAME (Flrst, Mlddie, Malden Surnamo)
<br />m Peter Pittz Sr Elizabeth Kaiser
<br />�' 13: EVER IN US. ARMED FORCES? Gtve dates of servlce ff Yea. 14a. INFORMANT�NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� {Yes, No, or unk.) Yes 02/26/1953-02/25/1955 Mike Pittz Son
<br />� 75,; MErHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. IICEN$E NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Derek Apfel 1240 October 29, 2010
<br />�,] CremaUon ❑ F.ntombmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CI1Y / TOWN STATE
<br />[] Removal ❑ Other (Specify)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17�. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, State} 17b. Zip Code
<br />74pfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />1& PAR71. EMer Ure chain ot evems--tliaeasea, Injuries, or compiicatlons•that dtrectty caused the death. DO NOT eMazterminal everrta euch as cardlac artest, ; qppROXIMATE INTERVAL
<br />'��, reapiratory arteat, or vemricuiar Nbrlllatlon wfthout showk�g the etlotogy. DO NOT ABBREVWTE F�nter only o�re cause on e ihre. Add addiGOnal Iirres H ne2esaery.
<br />IMMEDIATE CAUSE: ; ar�et to death
<br />IMMEDWTE CAUSE (Flnal a) Respiratory Failure . ; 10 Days
<br />tlf�ease or eontlitlon reau�Ung - - - - _. _. . _
<br />��' DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />SequentlaUy Itst candftlon& K b) Pneumonia ; 10 Days
<br />anr� �eaam¢ w ure cauae us�ed
<br />on lt�re a DUE TO, OR AS A CONSEQUENCE OF: p or�et to death
<br />EMerthe UNDERLYINO CAUSE C � � . .
<br />(tllaease or InJury that IniGated �
<br />the eve�rte resmdng In death� DUE TO, OR AS A CONSEQUENCE OF: 7 oriset t0 death
<br />� d)
<br />16. �pART II, OTHER SIGNIFICANT CONDITIONS-Conditlo� contributing to tha death but not resultlng In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />Congestive Heart Failure Colon Cancer OR CORONER CONTACTED?
<br />W ❑ YES � NO
<br />LL Z0. �F FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� Q Notpregnarrtwlthinpastyear � Natural � Homidda � Driver/OperaWr
<br />w Pregnarrt et nme ot aeau, p�� g�
<br />❑ ves Q No
<br />V � . � AcWdeM � PenAing Inveatl8ffi1on ❑ e .
<br />� �] Na preenaM, nus prepnaM whnm az aays ot aeau� 0 p��„ 27d. WERE AUTOPSY FINDINGS AVAILABLE
<br />a
<br />� � SWclde � Could not be tletermi�d ' TO COMPI.ETE CAUSE OF DEATH?
<br />� � Not P�eB�aM, but Pre9nant 49 days to 1 year bePore death . . �.� Other (BPedh)
<br />� unknown If prepngM within the past yaar ❑ YES ❑ NO
<br />E 22a', DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At homa, farm, atreet, factory, offlce buliding, consUvctton site, etc. (SpecHy)
<br />�
<br />a 22d. INJURY AT WORKT 22e. DESCRI9E HOW INJURY OCCURRED
<br />F�
<br />❑ ves ❑ No
<br />22f., LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.J 24b. TIflAEDEQEATH
<br />.� � October 24, 2010 ,� � �
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�� Z October 25, 2010 08:06 PM � y��
<br />$�� . To the best of my Imowletlge, tleath axuned at the tlme, date and place � 24e. On the basia of exaMnafinn endfw imesUgatlon, In my opinion death occurretl et
<br />� a�M due to the c a u s e( s) e t a t e tl. ( S l g n a t u re a n d T i de) ��� the time, date and laee end due to the ea
<br />o g $ P use(s) shated. (Slgneture and Tffle)
<br />'" � David R. Colan, MD '' $ g
<br />25. ID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />,Q YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotApplicable H26a Is NO ❑ YES ❑ NO
<br />E, TITLE D ADDRESS O RTIFI (P YSICIAN, HYSICIAN T T, CORONER' I OR OUNTY A ORNEl7 (Type or Pri�rt)
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />. ,
<br />October 26, 2010
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