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STATE OF NEBRASKA - �
<br />; ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND 1{f/MAN. S�RVI�,ES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK�,4�bEf�AR�'I'M`�I�(T OF H�'ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1�'7'�d�yFE�(h�4b�1�";�, y� �'
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<br />�iYa' �
<br />DATE OF ISSUANCE "" , �v°
<br />06/11/2009 2 0110 8 7 4 0 :� $TA S. C90R€l�' j ����, 3
<br />� � ,., � :
<br />d��rM�;,�v,�ro� �r�yc,fiH An�a ; ;
<br />LINCOLN, NEBRASKA �M(df�1RNSERU7CES, ,� �=� ,.�
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN S��2VICE8. �. " r 4'� •'� �� ��� A9 012d9
<br />CERTIFICATE OF DEATH �'; ""'�� '• ° ����;`� �'•' 1 � -
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, Suftbc) 2. SIX �L �, •�i a.� jun QF.. � 09 (Mo., Day, Yr.)
<br />Donald Dean Wonka Male � s ��, �,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Blrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY" `8: dATE OF BIRTH (Mo., Day, Yr.)
<br />(�'B•) MOS. DAYS HOURS MINS. ',
<br />Rosemont, Nebraska 81 Aprit 1, 1928
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />50&22-4214 IF OSPR �� InpaUerrt OTHER ❑ Nursing Home/I.TC � Hospice Faclllty
<br />8b. FACILIIY•NAME (B not Instidrtion, give street am! number) � ER/OutpaUeM ❑ Decedent"s Home
<br />�
<br />� Saint Francis Medical Center ❑ DOA ❑ onrer �spee�ry�
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<br />� Bc, CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNT1f OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9e. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL ed. STREET AND NUMBER e. APT. NO. 9L ZIP CODE 8g. INSIDE CITY LIMITS
<br />� 3104 Westside 68803 � ves ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Martled ❑ Never Manied 10b. NAME OF SPOUSE (First, Middle, Last, Suffiu) If wHe, give maiden name
<br />� � p nnamaa. a�n saAarat�d 0 uvidawea ❑ Dlvorced - �] Unknown 88�b2� Je2� Martin
<br />d - - -
<br />� 11. FATHER'S-NAME (Flrst, Middle, Last, Suifhc) 12. MOTHER'S-NAME (Flrat, Middle, Nlatden Sumame)
<br />� Frank Wonka Anna Barry
<br />°' 13. EVER IN U.S. ARMED FORCES4 GNe datea of aervice H Y�. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �res, No, or unk.) Yes Dates Unknown Barbara Jean Wonka Wife
<br />� 15; METHOD OF DISPOSI170N 16a. EMBALMERSIGNATURE 78b. UCENSE NO. 16c. DATE (Mo, Day, Yr.)
<br />F ❑ Burlal ❑ Donatlon
<br />Not Embalmed Juna 2, 2009
<br />� Crematlon ❑ EnWmbmeM 76d. CEME7ERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify) �ntral Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND NWILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE F DEAT See instructions and exam les
<br />1&��.PART I. Frrter the chaln ot eve�rte-.diaeasee, InJurlee, or comppcaflons-that dlreetiy caused the death. DO N0T e�rter terminal eve�rts aeh as cmdiae arrest, ; APPROXIMATE INTERYAL
<br />reaplratory artest, or ve�Mriwlar flbrl0atlon without showing the etlology. DO NOT ABBREVIATE EMer oniy orre cause on a Itrre. Add addidonal Nree H neeesaery.
<br />re
<br />IMMEDIATE CAUSE: ; oreet to death
<br />IMMEDIATE CAUSE (Flnal a) ACUTE GASTRIC BLEED ; 1-2 DAYS
<br />dieea� or canditlon reauttinp
<br />� d � ) DUE TO, OR AS A CONSEQUENCE OF: ' o�et to death
<br />SOqueMla11yl1atcondWon&H b)GASTRIC ULCER � WEEKS
<br />am, iesai� m me �suse natea
<br />on Itrre a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�,y,a�r,o�voeQCausE c)CHRONIC RENAL INSUFFICIENCY ; YEARS
<br />(dieeaae orl�JurythatlnRlated
<br />the eve� resuinng In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />I.A9T d)
<br />18, PART II.OTHER SIGNIFlCANT CONDITIONS-Conditlor� conMbuUng to the death but not resultlnp In the underiying cause gtven In PART I. 18. WAS MEDICAL EXAIWNER
<br />ISCHEMIC COLITIS OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE 27a. NL4NNER OF DEATH 27b. IF TRANSPORTATION INJURY 27e. W/6S AN AUTOPSY PERFORMED?
<br />� � Not pregnant wtthln past year � Naturel � Homleida � DNveAOperatoi �� � NO
<br />W � Pregna�rt at time of death Paseenger
<br />V � AcctdeM � Pendlnp Inveatigation ❑
<br />� NM pragnaM, but pre8� M'kh�� 42 deYe oT death gulcide Could not 6e demrmined ��eatr�e" 21d. WERE AUTOPSY FlNDINGS AVARABLE
<br />'� Q Not pregna�rt, but pregwrt 43 daya to t year betoro death � ❑ � pthe� �gpeqy� TO COMPLETE CAUSE OF DEATH?
<br />� � Unknown H pregnaMwithin tlre paat paar � .. . ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF WJURY 22e. PLACE OF INJURY-At home, farm, atreeR faetory, offlce bullding, constructlon site, ete. (Specify)
<br />c�
<br />� 22d. INJURY AT WORK? 228. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ ves ❑ No
<br />22t. LOCATION OF INJURY - STREET B NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day� Yr.) 24b. TIME OF DEATH
<br />.� � June 1, 2009 ,� � �
<br />�� Y 23b, DATE SIGNED (Mo., Day, Yr.) 23e.17ME OF DEATH ��� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />$ o o June 2, 2009 04:20 PM d<
<br />3d. To the Eeal ot my Imowledge, death occurted et the Ume, tlate and plaee ���� 24e. On tlre basle ot e�caminatlon artNar Imeatlpatlon, In my opinlon death occurted at
<br />�� aml due to the cause(e� atated. (3lgnature end TfUe) �&� the tlme, date and plaee anA due W Ne muse(e) sfatetl. (Signeture and Tkle)
<br />~ Gary Settje, MD '" � s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TIS9UE DONATION BEEN CONSIDERED7 26b. WA9 CONSENT GRANTED?
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applieable N 26a Is NO ❑ YES ❑ NO
<br />2: TITL D D ( R H SICIAN R (Type or r rn
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REOISTRAR'S SIONATURE �_ 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />'. June 9, 2009
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