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<br />STATE 0� NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT 0
<br />THE BELQW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W.ITH FHE-P
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSTTORY
<br />� G,
<br />DATE OP ISSUANCE , � , ;` �
<br />05/18/2010 � ,,=_ :
<br />�o�.�a�o59 � ,;�:
<br />LiNCOLN, NEBRASKA " �'_ •
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN°E
<br />y1a4tTH'�4ND,�,hIL/MAN SBRVICES, IT CERTIFIES
<br />'¢/tA��4 4��P,�F2i1MENT OF NEALTH AND
<br />31Y�.I�FT��_RE�O`RDS� � ;
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<br />:�"P'�tR`� '11%T Q� H�A�TI,•i�AtUD' .
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<br />RVJ �''•,..� � :� �`.TA f113d1
<br />CERTIFICATE OF DEATH �` ^�',� , ...',' • 1 �;" "' '- - - - -
<br />1. DECEDENTS-NAME (First, Middle, Last, Sufflx) �.. �. SEX ' � 1 ' ' 3. 4}1TE OF DEATH (Mo., Day, Yr.)
<br />Wayne Charles Cornel(us Male °��',"�' `� Apr1125; 2010
<br />4. CITY AND STATE OR TERRITORY, OR FORFJGN COUNTRY OF BIRTH Sa. AGE - Last 6lrthday . UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MO3. DAYS HOURS MINS.
<br />Blue Hill, Nebraska 77 October 27, 1932
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508 OSPR [] InpaUent OTHER ❑ Nuratn8 Home/LTC ❑ Hospice Faclilty
<br />8b, FACILITY-NAME ({i nnt Institutlon, gNe street and number) � EfYOutpatieirt ❑ Dec�denYs Home
<br />° Saint Francis Mediql Center [] ooa ❑ otner (s��ry}
<br />�
<br />� 8c: CITY OR TOWN OF DEATH (Includ6 Zip Code) Sd. COUNTY OF �EATH
<br />c Grand Island 68803 Hall
<br />� 8a: RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Alda
<br />� 9d. STREET AND Nl7MBER 9e. APT. NO. 8F. ZIP CODE 9g. INSIDE CITY LIMITS
<br />� 5731 S. 60 Rd. 68810 ❑� I� No
<br />� 10a. MARITAL STATUS AT TIM� OF DEATH � Marrled ❑ Never Marrled 70b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wHe, give malden �me
<br />� ❑ nn�maa but separated ❑�nnaow.a ❑ Dtvorced ❑ u��ow� ,lanna Rae Engel
<br />�
<br />11. FATHER'S-NAME (Flrat, Mlddie, Last, Suffix) 12. MOTHER'S-NAMH (First, Middte, Maiden Sumame)
<br />� Clarence Carl Comelius Helen Marle Stumpenhorst
<br />E 13.'EVER IN U.S. A.RMED FORCES4 G{ve dates oT se»Ice H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />g (ires, No, or uNc.) Yes 03/11/1953-02/10/1955 Janna Rae Comelius W�fe
<br />g' 15. IVIETHOD OF DISPOSITION 18a. EMBALMER�SIGNATURE 16b. LICENSE NO. 76c. DATE (Mo., Day, Yr.)
<br />F � Burtai ❑ vonatton Tracey Dietz 132$ Aprll 30, 2010
<br />� CremaUo� � Entombmant 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/ TOWN STATE
<br />❑ Removai ❑ otner (specrcy) �da Cemetery Alda Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Criy or 7own, Sfate) 17b. Zip Code
<br />apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 688Q1
<br />CAUS� OF DEATN See instructions and exam les
<br />19. PAR71. EMer the chaln oi eveMS� �dlseases, InJuNea, or Comppcatlonsdhet tllrectiy caused the death. DO NOT eMerterminal everhs euch ae cerdlac arreat, ; APPROXIMATE INTERVAL
<br />resplrsfory arteat, wveMric�dar8brlllatlon without showin8 ��ology. DO NOT ABBREVIATE EMer ontp one cause on a Iine. Atld additlonal Iin� H neceaeary. �
<br />IIbiMEDtATE CAUSE: = nrtse! ta �tfi
<br />IMMEDUUE CAU3B (Final a) Ruptured Myocardial Infarctlon With Massive Hemopencardfum And Cardiac Tamponade
<br />tltsease or condltlon �esuM�
<br />�" a �'� DUE TO, OR AS A CONSEQUENCE OF: ; o�etto death
<br />s�v„e,rc�,y ��s ��amo,�, e b) Severe Occlusive Calclftc Atherosclero�c Card(ovascular Disease
<br />amr� �eaatne co cne muae ��ea �
<br />on IUre a DUE TQ, QR r4S A CONSEQUENCE OF: 7 onset to death
<br />EMe� tlta UNDERLYIN6 CAUSE C )
<br />(disease or In)ury that lnidaled
<br />We eveMa resuitln8 �� d�) DUE 70, OR AS A CONSEQUENCE OR � : o�etto death
<br />LA9T � i
<br />18. PART It. OTHER SIGNIFlCANTCONDITIONS-CoiMlUOna coMributing to the death hut crot resulUng ta tha underlying cause givan tn PART I. 18. WAS MEDICAL EXAMINER
<br />Blunt Fores Trauma Of The Head With Focal Sutrdural And Subarachnofd Hemmorrage oR GoRONeR CoNracTen�
<br />" � ves ❑ No
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<br />2p. IF FEMALE: 27a. MANNER OF DEATH 21b. iF TRAMSPORTATIOt31NJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� ❑ NaaBe�ewnnmr�r� � ntaa,� � HoMUde , � DrWe70peratm � YES � nto
<br />� � PtagnaM etUme of deaW � peqdene � Pentlln8 ��8�� ❑���8er
<br />� � Not pregrta�rt, but pregnart wttMn 4z days ot death gWclde Could not be detertnlired ���O 21d. WERE AIITOPSY FINDINGS AVAILABL
<br />'� � Not preg�mny but pregnaM 0.9 daye to 1 year befo�e deatl� � � � � p�rye� �gpeciy) TO COMPI.ETE CAUSE OF DEATH?
<br />� � UnlmownHPreBnantwltNnUrepastYear � 1�E$ ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, farm, streeR factory, off►ee buliding, cor�truetlon site, etc. (SpecHy)
<br />E .
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW lN.lURY OCCURRED
<br />1�-
<br />o,�s ❑ No
<br />22f. LOCATION OF INJURY • STREE'f & NUMBER, APT.NO. CITYITOWN STATH ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, YrJ e 24a. OATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />,� �� May 14, 2010 07:00 PM
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ � o '� y < r � A ril 25, 2010 07:00 PM
<br />� Sd. To the hesf oi my Imowledge, death occurred at the dme, dete end P�ae � $��Z � 24e. On the basie af examinatlon and/or Invesdgatlon. In my op�nion death occurred at
<br />� and due to the cause(s) atated. (SlBnature and Tftle) � p the tlme, date and place and due to the ceuee(s) etated. (S18rtaWre and Title)
<br />� s ~ g s Jack 2'�tterkopf; Hall Deputy County Attomey
<br />25. D1D T09ACC0 USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO NotApplicable H28a ts NO ❑ YES ❑ NO
<br />2, E, ITLE AN DRE CE TIFIER (PHYSIC , S CIAN IS ANT, CORO ER SIC R A ORN (Type or PriM)
<br />Jack Zitterkopf, Hall Deputy County Attomey, 231 S. Locust, PA. Box 367, Grand lsland, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE �- 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 14, 2010
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